Provider Demographics
NPI:1649028309
Name:GILLIS, BRETT
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:GILLIS
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 1:1906 FORT JONES RD
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-9530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1906 FORT JONES RD
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-9530
Practice Address - Country:US
Practice Address - Phone:530-842-9060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63548183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA63548OtherBOARD OF PHARMACY LICENSE