Provider Demographics
NPI:1154067460
Name:BALOGA, BRIANNE JOAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRIANNE
Middle Name:JOAN
Last Name:BALOGA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12821 EXECUTIVE ACRES RD
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-5262
Mailing Address - Country:US
Mailing Address - Phone:651-276-9017
Mailing Address - Fax:
Practice Address - Street 1:13060 ISLE DR
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8331
Practice Address - Country:US
Practice Address - Phone:218-828-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14900-40183500000X
MN118851183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist