Provider Demographics
NPI:1225740517
Name:GESSELL, BRETT MONTANA
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:MONTANA
Last Name:GESSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 W BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1912
Mailing Address - Country:US
Mailing Address - Phone:208-785-8000
Mailing Address - Fax:
Practice Address - Street 1:960 W BRIDGE ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1912
Practice Address - Country:US
Practice Address - Phone:208-785-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP10459183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist