Provider Demographics
NPI:1972138246
Name:BRUNKHORST, BRUCE (RPH)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:BRUNKHORST
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 S 84TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2228
Mailing Address - Country:US
Mailing Address - Phone:619-804-6247
Mailing Address - Fax:
Practice Address - Street 1:10770 FORT ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-1230
Practice Address - Country:US
Practice Address - Phone:402-493-3257
Practice Address - Fax:402-493-0150
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-07
Last Update Date:2020-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46038183500000X
NE10156183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist