Provider Demographics
NPI:1427653856
Name:WILLARD, BRIANNA
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:WILLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4337 RENAISSANCE DR APT 321
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95134-2809
Mailing Address - Country:US
Mailing Address - Phone:781-608-0082
Mailing Address - Fax:
Practice Address - Street 1:4110 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95134-1513
Practice Address - Country:US
Practice Address - Phone:408-434-1839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83504183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist