Provider Demographics
NPI:1194326579
Name:WEIDNER, BRANDON ALAN
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:ALAN
Last Name:WEIDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-1153
Mailing Address - Country:US
Mailing Address - Phone:317-642-8505
Mailing Address - Fax:
Practice Address - Street 1:400 W NORTHFIELD DR
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-8122
Practice Address - Country:US
Practice Address - Phone:317-858-1415
Practice Address - Fax:317-858-1796
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26025549A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist