Provider Demographics
NPI:1164722179
Name:PRINCE, BRYAN W (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:W
Last Name:PRINCE
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 1:361 GLENMORE AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-5217
Mailing Address - Country:US
Mailing Address - Phone:901-355-6914
Mailing Address - Fax:
Practice Address - Street 1:9983 BLUEBONNET BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-6458
Practice Address - Country:US
Practice Address - Phone:225-769-4208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.019271183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAMA001133OtherLOUISIANA BOARD OF PHARMACY
LAPST091271OtherLOUISIANA BOARD OF PHARMACY
LA1079256OtherWALGREENS