Provider Demographics
NPI:1588994586
Name:BRUBAKER, RODGER WILLIAM (PHARMACIST)
Entity type:Individual
Prefix:
First Name:RODGER
Middle Name:WILLIAM
Last Name:BRUBAKER
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1641
Mailing Address - Country:US
Mailing Address - Phone:928-773-1155
Mailing Address - Fax:928-773-1652
Practice Address - Street 1:1500 E CEDAR AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1641
Practice Address - Country:US
Practice Address - Phone:928-773-1155
Practice Address - Fax:928-773-1652
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS006900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist