Provider Demographics
NPI:1215216841
Name:BRUNELLE, ADAM
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:BRUNELLE
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 1:2093 E MARLENE DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-1523
Mailing Address - Country:US
Mailing Address - Phone:623-210-3378
Mailing Address - Fax:
Practice Address - Street 1:4440 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-7902
Practice Address - Country:US
Practice Address - Phone:480-218-8573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-13
Last Update Date:2011-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS018503183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist