Provider Demographics
NPI:1548632961
Name:CHRISTENSON, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CHRISTENSON
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 1:1832 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6464
Mailing Address - Country:US
Mailing Address - Phone:208-317-7133
Mailing Address - Fax:
Practice Address - Street 1:500 S UTAH AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3305
Practice Address - Country:US
Practice Address - Phone:208-528-8703
Practice Address - Fax:208-528-8695
Is Sole Proprietor?:No
Enumeration Date:2015-10-25
Last Update Date:2015-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5581183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist