Provider Demographics
NPI:1518558741
Name:BRYANT, CHARLES MARVIN JR
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:MARVIN
Last Name:BRYANT
Suffix:JR
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 1:1609 ZUNI RD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1620
Mailing Address - Country:US
Mailing Address - Phone:719-568-5009
Mailing Address - Fax:
Practice Address - Street 1:2730 S PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-3167
Practice Address - Country:US
Practice Address - Phone:719-696-6159
Practice Address - Fax:719-696-6170
Is Sole Proprietor?:No
Enumeration Date:2021-01-30
Last Update Date:2021-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHATP.0006919183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician