Provider Demographics
NPI:1811121544
Name:BRAXTON, BART R (RPH)
Entity type:Individual
Prefix:
First Name:BART
Middle Name:R
Last Name:BRAXTON
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 1:9007 N INDIAN TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-9116
Mailing Address - Country:US
Mailing Address - Phone:509-464-2791
Mailing Address - Fax:
Practice Address - Street 1:9007 N INDIAN TRAIL RD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-9116
Practice Address - Country:US
Practice Address - Phone:509-464-2791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-10
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 00016318183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist