Provider Demographics
NPI:1295010197
Name:TOOTLE, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:TOOTLE
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 1:510 STRATFORD CT APT 201A
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-2766
Mailing Address - Country:US
Mailing Address - Phone:858-342-8905
Mailing Address - Fax:
Practice Address - Street 1:3005 MIDWAY DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4502
Practice Address - Country:US
Practice Address - Phone:619-221-0834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61627183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist