Provider Demographics
NPI:1114534336
Name:NELSON, BRYN MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRYN
Middle Name:MICHAEL
Last Name:NELSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 ROBINS WAY
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22664-2084
Mailing Address - Country:US
Mailing Address - Phone:435-215-5883
Mailing Address - Fax:
Practice Address - Street 1:743 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOOREFIELD
Practice Address - State:WV
Practice Address - Zip Code:26836-1020
Practice Address - Country:US
Practice Address - Phone:435-215-5883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0011791183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist