Provider Demographics
NPI:1164017745
Name:BREWER, MARK T (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:BREWER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2298 11TH ST
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-2613
Mailing Address - Country:US
Mailing Address - Phone:651-497-7000
Mailing Address - Fax:
Practice Address - Street 1:10240 HUDSON RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55129-9111
Practice Address - Country:US
Practice Address - Phone:651-735-5190
Practice Address - Fax:651-735-5193
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116916183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist