Provider Demographics
NPI:1104489467
Name:TA, BRANDY (PHARMACIST)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:TA
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1870A
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92842-5126
Mailing Address - Country:US
Mailing Address - Phone:714-251-9100
Mailing Address - Fax:
Practice Address - Street 1:1875 N KRAEMER BLVD
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-2616
Practice Address - Country:US
Practice Address - Phone:714-572-5656
Practice Address - Fax:714-572-5662
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-22
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56351183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist