Provider Demographics
NPI:1801496286
Name:MCCULLOUGH, BRYAN ANDREW (PHARMD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:ANDREW
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5921 LYNDHURST DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-5117
Mailing Address - Country:US
Mailing Address - Phone:409-939-8596
Mailing Address - Fax:
Practice Address - Street 1:5501 SHERWOOD WAY
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-9738
Practice Address - Country:US
Practice Address - Phone:325-942-7682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33814183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist