Provider Demographics
NPI:1588256275
Name:HERCULES, BRYAN JOSEPH (RPH, MS)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:JOSEPH
Last Name:HERCULES
Suffix:
Gender:M
Credentials:RPH, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2514 WOODSON RD
Mailing Address - Street 2:
Mailing Address - City:OVERLAND
Mailing Address - State:MO
Mailing Address - Zip Code:63114-5437
Mailing Address - Country:US
Mailing Address - Phone:314-427-1818
Mailing Address - Fax:314-423-9905
Practice Address - Street 1:2514 WOODSON RD
Practice Address - Street 2:
Practice Address - City:OVERLAND
Practice Address - State:MO
Practice Address - Zip Code:63114-5437
Practice Address - Country:US
Practice Address - Phone:314-427-1818
Practice Address - Fax:314-423-9905
Is Sole Proprietor?:No
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600279202Medicaid