Provider Demographics
NPI:1083210009
Name:STUART, BRENT
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:STUART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7191 10TH ST N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5943
Mailing Address - Country:US
Mailing Address - Phone:651-731-7961
Mailing Address - Fax:651-731-7964
Practice Address - Street 1:7191 10TH ST N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-5943
Practice Address - Country:US
Practice Address - Phone:651-731-7961
Practice Address - Fax:651-731-7964
Is Sole Proprietor?:No
Enumeration Date:2020-12-06
Last Update Date:2020-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123014183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist