Provider Demographics
NPI:1699465559
Name:HENDERSON, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4854 WOODBINE RD UNIT 5
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-8709
Mailing Address - Country:US
Mailing Address - Phone:850-463-0022
Mailing Address - Fax:850-994-7979
Practice Address - Street 1:4854 WOODBINE RD UNIT 5
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-8709
Practice Address - Country:US
Practice Address - Phone:850-463-0022
Practice Address - Fax:850-994-7979
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS29768183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist