Provider Demographics
NPI:1700241635
Name:BARNES, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BARNES
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 1:540 W 5TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:540 W 5TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5034
Practice Address - Country:US
Practice Address - Phone:432-332-1623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-18
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX54830183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist