Provider Demographics
NPI:1427336577
Name:MEHL, BRAXTON TRISTAN MICHAEL (PHARMD)
Entity type:Individual
Prefix:DR
First Name:BRAXTON
Middle Name:TRISTAN MICHAEL
Last Name:MEHL
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 1:2000 CRATER LAKE HWY
Mailing Address - Street 2:T-0613
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4161
Mailing Address - Country:US
Mailing Address - Phone:541-779-5110
Mailing Address - Fax:
Practice Address - Street 1:2000 CRATER LAKE HWY
Practice Address - Street 2:T-0613
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4161
Practice Address - Country:US
Practice Address - Phone:541-779-5110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-22
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0012677183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist