Provider Demographics
NPI:1790993095
Name:BRANNUM, MARVA ANDERSON (RPH)
Entity Type:Individual
Prefix:
First Name:MARVA
Middle Name:ANDERSON
Last Name:BRANNUM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 CORDOVA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91207-1732
Mailing Address - Country:US
Mailing Address - Phone:818-243-0663
Mailing Address - Fax:818-243-0068
Practice Address - Street 1:1864 E WASHINGTON BLVD STE 105
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-1667
Practice Address - Country:US
Practice Address - Phone:626-398-1696
Practice Address - Fax:626-398-9860
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA469091835P0018X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA46909OtherPHARMACY LICENSE