Provider Demographics
NPI:1306459490
Name:HARRIS, BRYAN DAVID
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:DAVID
Last Name:HARRIS
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 1:310 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MO
Mailing Address - Zip Code:63863-2116
Mailing Address - Country:US
Mailing Address - Phone:573-281-6964
Mailing Address - Fax:573-276-4785
Practice Address - Street 1:310 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MO
Practice Address - Zip Code:63863-2116
Practice Address - Country:US
Practice Address - Phone:573-281-6964
Practice Address - Fax:573-276-4785
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042982183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist