Provider Demographics
NPI:1114540499
Name:BROWN, NATHANIEL GEORGE (PHARMD)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:GEORGE
Last Name:BROWN
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 1:1064 BUTLER DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CA
Mailing Address - Zip Code:93523-2623
Mailing Address - Country:US
Mailing Address - Phone:626-474-5012
Mailing Address - Fax:
Practice Address - Street 1:412TH MEDICAL GROUP 30 NIGHTINGALE RD.
Practice Address - Street 2:BUILDING #5525
Practice Address - City:EDWARDS AIR FORCE BASE
Practice Address - State:CA
Practice Address - Zip Code:93524
Practice Address - Country:US
Practice Address - Phone:661-277-7118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06015221390200000X
OH03440116183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program