Provider Demographics
NPI:1760162218
Name:POWELL, BRANDON DEAN
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:DEAN
Last Name:POWELL
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 1:11492 S CAMDEN RD
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9049
Mailing Address - Country:US
Mailing Address - Phone:801-897-9253
Mailing Address - Fax:
Practice Address - Street 1:1100 S VISTA AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2429
Practice Address - Country:US
Practice Address - Phone:208-344-2529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP10779183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist