Provider Demographics
NPI:1386913200
Name:THEISEN, BRANDON J (PHARMD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:J
Last Name:THEISEN
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 1:5523 SW 92ND WAY
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-4328
Mailing Address - Country:US
Mailing Address - Phone:407-770-8251
Mailing Address - Fax:
Practice Address - Street 1:4899 NW BLITCHTON RD
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34482-8743
Practice Address - Country:US
Practice Address - Phone:352-622-8753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS44178183500000X
OH03328727183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist