Provider Demographics
NPI:1033862701
Name:RENOUD, BRIAN DEAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:DEAN
Last Name:RENOUD
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 1:20584 US HIGHWAY 54
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62363-2745
Mailing Address - Country:US
Mailing Address - Phone:217-248-8425
Mailing Address - Fax:
Practice Address - Street 1:500 N HIGHWAY 90 BYP
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2204
Practice Address - Country:US
Practice Address - Phone:520-458-9690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS025717183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist