Provider Demographics
NPI:1477975902
Name:MCINTOSH, BRENT
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:MCINTOSH
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 1:11626 S PRESCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-6848
Mailing Address - Country:US
Mailing Address - Phone:623-258-1639
Mailing Address - Fax:
Practice Address - Street 1:2501 S AVENUE B
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7734
Practice Address - Country:US
Practice Address - Phone:928-317-6863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS007806183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist