Provider Demographics
NPI:1447582465
Name:LANGE, BRENT NELSON (RPH)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:NELSON
Last Name:LANGE
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 1:899 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1109
Mailing Address - Country:US
Mailing Address - Phone:716-885-2833
Mailing Address - Fax:716-504-5657
Practice Address - Street 1:899 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1109
Practice Address - Country:US
Practice Address - Phone:716-885-2833
Practice Address - Fax:716-504-5657
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-01
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038792183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist