Provider Demographics
NPI:1558650267
Name:BRUBAKER, RICHARD E (RPH)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:BRUBAKER
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 1:900 HOGANSVILLE RD
Mailing Address - Street 2:SUITE K
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-1467
Mailing Address - Country:US
Mailing Address - Phone:706-882-0161
Mailing Address - Fax:706-884-7474
Practice Address - Street 1:900 HOGANSVILLE RD
Practice Address - Street 2:SUITE K
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-1467
Practice Address - Country:US
Practice Address - Phone:706-882-0161
Practice Address - Fax:706-884-7474
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH011955183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist