Provider Demographics
NPI:1578231759
Name:RALEY, BRENT
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:RALEY
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 1:997 BLENHEIM RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43224-2620
Mailing Address - Country:US
Mailing Address - Phone:270-945-3301
Mailing Address - Fax:
Practice Address - Street 1:88 MCMILLEN DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1809
Practice Address - Country:US
Practice Address - Phone:220-564-1898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH034408921835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care