Provider Demographics
NPI:1831405851
Name:CARLSON, BRUCE (BRUCE CARLSON)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:CARLSON
Suffix:
Gender:M
Credentials:BRUCE CARLSON
Other - Prefix:
Other - First Name:BRUCE
Other - Middle Name:
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:511 CLEAR CREEK LN
Mailing Address - Street 2:
Mailing Address - City:DRIPPING SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78620-3931
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:598 E HIGHWAY 290
Practice Address - Street 2:
Practice Address - City:DRIPPING SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:78620-3931
Practice Address - Country:US
Practice Address - Phone:512-858-0314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22544183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist