Provider Demographics
NPI:1629688445
Name:BRUCH, DAVID
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:BRUCH
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 1:5419 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5738
Mailing Address - Country:US
Mailing Address - Phone:307-766-6064
Mailing Address - Fax:
Practice Address - Street 1:3112 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5141
Practice Address - Country:US
Practice Address - Phone:307-745-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3358183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist