Provider Demographics
NPI:1063719458
Name:BRAZO, JAMIE LYNN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:LYNN
Last Name:BRAZO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 W WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46619-2641
Mailing Address - Country:US
Mailing Address - Phone:574-246-0052
Mailing Address - Fax:574-246-0293
Practice Address - Street 1:4444 W WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46619-2641
Practice Address - Country:US
Practice Address - Phone:574-246-0052
Practice Address - Fax:574-246-0293
Is Sole Proprietor?:No
Enumeration Date:2011-02-21
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26021630A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist