Provider Demographics
NPI:1275851776
Name:DEBOLT, BRYAN ANDREW (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:ANDREW
Last Name:DEBOLT
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 1:2628 STATE ROUTE 97
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44904-9518
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:335 GLESSNER AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2269
Practice Address - Country:US
Practice Address - Phone:419-526-8572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2010-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRPH.03129807183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist