Provider Demographics
NPI:1366315004
Name:SMITH, BRIAN DOUGLAS
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:DOUGLAS
Last Name:SMITH
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 1:6231 COPPER VALLEY CT NE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-8706
Mailing Address - Country:US
Mailing Address - Phone:616-334-8408
Mailing Address - Fax:
Practice Address - Street 1:6231 COPPER VALLEY CT NE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-8706
Practice Address - Country:US
Practice Address - Phone:616-334-8408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-29
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302033585183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist