Provider Demographics
NPI:1124592340
Name:FOREMAN, BRENNAN JAMES (PHARMACY INTERN)
Entity Type:Individual
Prefix:
First Name:BRENNAN
Middle Name:JAMES
Last Name:FOREMAN
Suffix:
Gender:M
Credentials:PHARMACY INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 LEXINGTON AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-5649
Mailing Address - Country:US
Mailing Address - Phone:614-440-4387
Mailing Address - Fax:
Practice Address - Street 1:355 54TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49548-5614
Practice Address - Country:US
Practice Address - Phone:616-552-6226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302044620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist