Provider Demographics
NPI:1619247186
Name:BRYAN, JOE PAUL (RPH)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:PAUL
Last Name:BRYAN
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 1:11441 DORONHURST DR
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE FORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23140-4436
Mailing Address - Country:US
Mailing Address - Phone:804-966-8150
Mailing Address - Fax:
Practice Address - Street 1:573 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KILMARNOCK
Practice Address - State:VA
Practice Address - Zip Code:22482-3828
Practice Address - Country:US
Practice Address - Phone:804-435-8890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202204416183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist