Provider Demographics
NPI:1316997935
Name:BRUECKL, MARK NELSON (RPH, MBA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:NELSON
Last Name:BRUECKL
Suffix:
Gender:M
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:10 COLLINS CT
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-6551
Mailing Address - Country:US
Mailing Address - Phone:540-288-0792
Mailing Address - Fax:703-683-8417
Practice Address - Street 1:100 N PITT ST
Practice Address - Street 2:SUITE 400
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-3134
Practice Address - Country:US
Practice Address - Phone:703-683-8416
Practice Address - Fax:703-683-8417
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030718183500000X
VA0202207378183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist