Provider Demographics
NPI:1215695614
Name:JENS, BRADY M (RPH)
Entity type:Individual
Prefix:
First Name:BRADY
Middle Name:M
Last Name:JENS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1638 NORTHSTAR CT
Mailing Address - Street 2:
Mailing Address - City:GARDNERVILLE
Mailing Address - State:NV
Mailing Address - Zip Code:89410-7624
Mailing Address - Country:US
Mailing Address - Phone:970-270-3050
Mailing Address - Fax:
Practice Address - Street 1:1638 NORTHSTAR CT
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-7624
Practice Address - Country:US
Practice Address - Phone:970-270-3050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA00162191835N0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835N0905XPharmacy Service ProvidersPharmacistNuclear