Provider Demographics
NPI:1326584897
Name:ROSS, BRENNA
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:
Last Name:ROSS
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 1:6135 SISSONVILLE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25312-9444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6135 SISSONVILLE DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25312-9444
Practice Address - Country:US
Practice Address - Phone:304-343-8030
Practice Address - Fax:304-343-8031
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0009978183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist