Provider Demographics
NPI:1396179057
Name:MASON, BRIAN JAMES (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JAMES
Last Name:MASON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6652 YOUREE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105
Mailing Address - Country:US
Mailing Address - Phone:318-795-0506
Mailing Address - Fax:318-795-0510
Practice Address - Street 1:6652 YOUREE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4630
Practice Address - Country:US
Practice Address - Phone:318-795-0506
Practice Address - Fax:318-795-0510
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15629183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA15629OtherPHARMACIST CREDENTIAL