Provider Demographics
NPI:1124258058
Name:ELDRIDGE, BRANDON GLEN (PHARMD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:GLEN
Last Name:ELDRIDGE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1304
Mailing Address - Country:US
Mailing Address - Phone:314-535-3334
Mailing Address - Fax:314-535-3337
Practice Address - Street 1:1504 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1304
Practice Address - Country:US
Practice Address - Phone:314-535-3334
Practice Address - Fax:314-535-3337
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009020986183500000X
IL051.294668183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600447627Medicaid