Provider Demographics
NPI:1649560160
Name:RILEY, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:RILEY
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 1:110 ROSEMEAD AVE
Mailing Address - Street 2:
Mailing Address - City:SINKING SPRING
Mailing Address - State:PA
Mailing Address - Zip Code:19608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4810 PENN AVE
Practice Address - Street 2:
Practice Address - City:SINKING SPRING
Practice Address - State:PA
Practice Address - Zip Code:19608-8601
Practice Address - Country:US
Practice Address - Phone:610-670-9986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP444057183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist