Provider Demographics
NPI:1922471887
Name:BRAULT, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:BRAULT
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 1:288 CORNELIA ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:288 CORNELIA ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2303
Practice Address - Country:US
Practice Address - Phone:518-561-3510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-01
Last Update Date:2015-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055829183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist