Provider Demographics
NPI:1760755110
Name:BLACK, BRENNAN DUANE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRENNAN
Middle Name:DUANE
Last Name:BLACK
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 1:884 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-3233
Mailing Address - Country:US
Mailing Address - Phone:541-636-3522
Mailing Address - Fax:
Practice Address - Street 1:175 E OREGON AVE
Practice Address - Street 2:
Practice Address - City:CRESWELL
Practice Address - State:OR
Practice Address - Zip Code:97426-9674
Practice Address - Country:US
Practice Address - Phone:541-895-2413
Practice Address - Fax:541-895-2436
Is Sole Proprietor?:No
Enumeration Date:2012-02-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-00127631835P0018X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRPH-0012763OtherSTATE PHARMACIST LICENSE