Provider Demographics
NPI:1144471467
Name:BRANUM, MARK N (RPH, PHARMD, CGP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:N
Last Name:BRANUM
Suffix:
Gender:M
Credentials:RPH, PHARMD, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-2317
Mailing Address - Country:US
Mailing Address - Phone:563-382-8765
Mailing Address - Fax:563-382-1329
Practice Address - Street 1:702 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-2317
Practice Address - Country:US
Practice Address - Phone:563-382-8765
Practice Address - Fax:563-382-1329
Is Sole Proprietor?:No
Enumeration Date:2008-10-06
Last Update Date:2014-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20505183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist