Provider Demographics
NPI:1619195914
Name:BRUNNER, MICHAEL BARRY (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BARRY
Last Name:BRUNNER
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 1:8220 STATE ROUTE 101
Mailing Address - Street 2:
Mailing Address - City:CASTALIA
Mailing Address - State:OH
Mailing Address - Zip Code:44824
Mailing Address - Country:US
Mailing Address - Phone:419-684-1011
Mailing Address - Fax:
Practice Address - Street 1:234 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:OH
Practice Address - Zip Code:44811
Practice Address - Country:US
Practice Address - Phone:419-483-3784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-25306183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist