Provider Demographics
NPI:1558878827
Name:JAN, BRIAN ETHAN (RPH)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ETHAN
Last Name:JAN
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 1:2705 PINE LAKE DR APT 2705
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-5865
Mailing Address - Country:US
Mailing Address - Phone:858-837-4620
Mailing Address - Fax:
Practice Address - Street 1:3333 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3842
Practice Address - Country:US
Practice Address - Phone:318-445-6386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.022336183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist