Provider Demographics
NPI:1669456109
Name:BRANDT, STEPHEN W (RPH)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:W
Last Name:BRANDT
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 1:1614 CAMPHOR WAY
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-4420
Mailing Address - Country:US
Mailing Address - Phone:209-339-9805
Mailing Address - Fax:209-334-2203
Practice Address - Street 1:610 W KETTLEMAN LN
Practice Address - Street 2:S-MART PHARMACY
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-6050
Practice Address - Country:US
Practice Address - Phone:209-339-9805
Practice Address - Fax:209-334-2203
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31823183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist