Provider Demographics
NPI:1669754735
Name:MILLARD, BRENT ALAN (RPH)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:ALAN
Last Name:MILLARD
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 1:6746 CLEARWATER CREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55038-7706
Mailing Address - Country:US
Mailing Address - Phone:651-653-7532
Mailing Address - Fax:
Practice Address - Street 1:1207 WEST BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025
Practice Address - Country:US
Practice Address - Phone:651-255-1887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN115249183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist