Provider Demographics
NPI:1710558838
Name:PORTER, BRYAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:PORTER
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 1:288 W PICARDY ST
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-7866
Mailing Address - Country:US
Mailing Address - Phone:417-247-5132
Mailing Address - Fax:
Practice Address - Street 1:3020 S ELLIOTT AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-9663
Practice Address - Country:US
Practice Address - Phone:417-678-6006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021026212183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist