Provider Demographics
NPI:1811597057
Name:HORNER, BRENTON DAVE
Entity Type:Individual
Prefix:MR
First Name:BRENTON
Middle Name:DAVE
Last Name:HORNER
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 1:2716 ENID DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-1909
Mailing Address - Country:US
Mailing Address - Phone:214-729-8967
Mailing Address - Fax:
Practice Address - Street 1:1801 MARKETPLACE DR
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-5605
Practice Address - Country:US
Practice Address - Phone:972-279-8728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12621183500000X
TX38462183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist