Provider Demographics
NPI:1235213539
Name:GAINES, BRANDY LEANN
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:LEANN
Last Name:GAINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 S 2ND ST
Mailing Address - Street 2:PO BOX 497
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-2309
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:
Practice Address - Street 1:615 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRINKLEY
Practice Address - State:AR
Practice Address - Zip Code:72021-2507
Practice Address - Country:US
Practice Address - Phone:870-734-1153
Practice Address - Fax:870-734-1179
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT89535183700000X
ARPD11925183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No183700000XPharmacy Service ProvidersPharmacy Technician