Provider Demographics
NPI:1639452113
Name:WILLETT, BRYAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:WILLETT
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:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:SMITHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:42081-0010
Mailing Address - Country:US
Mailing Address - Phone:270-928-2161
Mailing Address - Fax:270-928-2293
Practice Address - Street 1:203 E ADAIR ST
Practice Address - Street 2:
Practice Address - City:SMITHLAND
Practice Address - State:KY
Practice Address - Zip Code:42081-9164
Practice Address - Country:US
Practice Address - Phone:270-928-2161
Practice Address - Fax:270-928-2293
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY014635183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY014635OtherPHARMACIST LICENSE