Provider Demographics
NPI:1821485061
Name:THOMPSON, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:THOMPSON
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 1:1160 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LAKE VIEW
Mailing Address - State:IA
Mailing Address - Zip Code:51450-7612
Mailing Address - Country:US
Mailing Address - Phone:712-665-8554
Mailing Address - Fax:712-665-2749
Practice Address - Street 1:1160 3RD ST
Practice Address - Street 2:
Practice Address - City:LAKE VIEW
Practice Address - State:IA
Practice Address - Zip Code:51450-7612
Practice Address - Country:US
Practice Address - Phone:712-665-8554
Practice Address - Fax:712-665-2749
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15805183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist