Provider Demographics
NPI:1275082455
Name:WILLIS, BRANDON LOUIS (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:LOUIS
Last Name:WILLIS
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 1:12805 HIGHWAY 28 E
Mailing Address - Street 2:SUITE A
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-0704
Mailing Address - Country:US
Mailing Address - Phone:318-466-3113
Mailing Address - Fax:
Practice Address - Street 1:12805 HIGHWAY 28 E
Practice Address - Street 2:SUITE A
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-0704
Practice Address - Country:US
Practice Address - Phone:318-466-3113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.018198183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist