Provider Demographics
NPI:1467710269
Name:WELCH, BRIAN JACOB
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JACOB
Last Name:WELCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N 1ST ST BLDG 46
Mailing Address - Street 2:
Mailing Address - City:ALTUS AFB
Mailing Address - State:OK
Mailing Address - Zip Code:73523-5004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 N 1ST ST BLDG 46
Practice Address - Street 2:
Practice Address - City:ALTUS AFB
Practice Address - State:OK
Practice Address - Zip Code:73523-5004
Practice Address - Country:US
Practice Address - Phone:580-481-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2022-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 493421835P0018X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist