Provider Demographics
NPI:1538758156
Name:STARK, BRANDIE (RPH)
Entity type:Individual
Prefix:
First Name:BRANDIE
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 S OHARE BLVD
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47396-6865
Mailing Address - Country:US
Mailing Address - Phone:765-760-0364
Mailing Address - Fax:
Practice Address - Street 1:3631 N MORRISON RD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5547
Practice Address - Country:US
Practice Address - Phone:765-213-2866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020562A1835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care