Provider Demographics
NPI:1205554433
Name:BRANSON, SOPHIE
Entity type:Individual
Prefix:
First Name:SOPHIE
Middle Name:
Last Name:BRANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3740 W TRUMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-0537
Mailing Address - Country:US
Mailing Address - Phone:573-893-1044
Mailing Address - Fax:
Practice Address - Street 1:3740 W TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-0537
Practice Address - Country:US
Practice Address - Phone:573-893-1044
Practice Address - Fax:573-893-1041
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010033599183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist