Provider Demographics
NPI:1760930887
Name:CULLEN, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:CULLEN
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 1:23505 E MAPLE HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80138-5717
Mailing Address - Country:US
Mailing Address - Phone:303-519-2405
Mailing Address - Fax:
Practice Address - Street 1:3333 CLARK ST
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2050
Practice Address - Country:US
Practice Address - Phone:719-589-9071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-18
Last Update Date:2016-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0021356183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist