Provider Demographics
NPI:1255691622
Name:BRYANT, RODNEY RAY (RPH)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:RAY
Last Name:BRYANT
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 1:2805 PASCOE LN
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-8244
Mailing Address - Country:US
Mailing Address - Phone:208-880-7488
Mailing Address - Fax:
Practice Address - Street 1:2400 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6300
Practice Address - Country:US
Practice Address - Phone:208-463-2903
Practice Address - Fax:208-468-0215
Is Sole Proprietor?:No
Enumeration Date:2012-05-20
Last Update Date:2012-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5115183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist