Provider Demographics
NPI:1831250638
Name:WOODS, BRYAN EARL (R PH)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:EARL
Last Name:WOODS
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-2043
Mailing Address - Country:US
Mailing Address - Phone:760-789-0180
Mailing Address - Fax:760-789-7945
Practice Address - Street 1:677 MAIN ST
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-2043
Practice Address - Country:US
Practice Address - Phone:760-789-0180
Practice Address - Fax:760-789-7945
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29211183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA462900Medicaid
CAPHA462900Medicaid