Provider Demographics
NPI:1417552001
Name:HETZELL, BRANDON RICHARD (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:RICHARD
Last Name:HETZELL
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 1:69 RANDOLPH RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-3845
Mailing Address - Country:US
Mailing Address - Phone:609-501-9776
Mailing Address - Fax:
Practice Address - Street 1:1163 E CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-5001
Practice Address - Country:US
Practice Address - Phone:856-205-7371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03668300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0012220Medicaid