Provider Demographics
NPI:1619299880
Name:BRENNER, ROBERT (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:BRENNER
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2814
Mailing Address - Country:US
Mailing Address - Phone:631-473-2914
Mailing Address - Fax:631-473-8865
Practice Address - Street 1:464 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2814
Practice Address - Country:US
Practice Address - Phone:631-473-2914
Practice Address - Fax:631-473-8865
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024743183500000X
AZ6778183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist