Provider Demographics
NPI:1669772463
Name:GUBERUD, BRIAN
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:GUBERUD
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 1:1701 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-1925
Mailing Address - Country:US
Mailing Address - Phone:303-278-2284
Mailing Address - Fax:303-278-7057
Practice Address - Street 1:1701 JACKSON ST
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401-1925
Practice Address - Country:US
Practice Address - Phone:303-278-2284
Practice Address - Fax:303-278-7057
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18461183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist