Provider Demographics
NPI:1053695718
Name:BROOKS, BRYAN WESLEY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:WESLEY
Last Name:BROOKS
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 1:19 BURGHER DR
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3602
Mailing Address - Country:US
Mailing Address - Phone:314-488-8631
Mailing Address - Fax:
Practice Address - Street 1:1375 E 10TH ST STE B
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3591
Practice Address - Country:US
Practice Address - Phone:573-364-9616
Practice Address - Fax:573-341-3986
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002029007183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist