Provider Demographics
NPI:1558029181
Name:BRISKE, BRYAN H
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:H
Last Name:BRISKE
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 1:3949 FARR RD
Mailing Address - Street 2:
Mailing Address - City:FRUITPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49415-9309
Mailing Address - Country:US
Mailing Address - Phone:231-578-0658
Mailing Address - Fax:
Practice Address - Street 1:1550 LAKE DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2704
Practice Address - Country:US
Practice Address - Phone:616-235-0747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI21251020901183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist