Provider Demographics
NPI:1023644390
Name:COLLINS, BRIAN JAMES
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JAMES
Last Name:COLLINS
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 1:1131 CEDAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:NORTHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:43619-2656
Mailing Address - Country:US
Mailing Address - Phone:419-349-8165
Mailing Address - Fax:
Practice Address - Street 1:1175 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-2537
Practice Address - Country:US
Practice Address - Phone:419-874-3587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03439117183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03439117OtherRPH LICENSE