Provider Demographics
NPI:1699426866
Name:BAUTISTA, BRANDON (PHARMD)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
Last Name:BAUTISTA
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 1:13285 EARLY FROST CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7438
Mailing Address - Country:US
Mailing Address - Phone:407-608-9185
Mailing Address - Fax:
Practice Address - Street 1:2400 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-3097
Practice Address - Country:US
Practice Address - Phone:386-756-9969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS61502183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist