Provider Demographics
NPI:1407506173
Name:BRANSON, MIKE CAREY (RPH)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:CAREY
Last Name:BRANSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11810 RR 620 N
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-1347
Mailing Address - Country:US
Mailing Address - Phone:512-258-2459
Mailing Address - Fax:
Practice Address - Street 1:11810 RR 620 N
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-1347
Practice Address - Country:US
Practice Address - Phone:512-258-2459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist