Provider Demographics
NPI:1578818050
Name:DAUGHERTY, BRENT (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 S ROAN ST
Mailing Address - Street 2:APT 202
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-5704
Mailing Address - Country:US
Mailing Address - Phone:423-572-1017
Mailing Address - Fax:
Practice Address - Street 1:606 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-3535
Practice Address - Country:US
Practice Address - Phone:423-232-1524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36932183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist