Provider Demographics
NPI:1215463690
Name:STEWART, BRIAN S (PHARMD)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:S
Last Name:STEWART
Suffix:
Gender:M
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:PO BOX 1706
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1706
Mailing Address - Country:US
Mailing Address - Phone:208-772-3311
Mailing Address - Fax:208-772-1779
Practice Address - Street 1:240 W HAYDEN AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8194
Practice Address - Country:US
Practice Address - Phone:208-772-3311
Practice Address - Fax:208-772-1779
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5350183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist