Provider Demographics
NPI:1861985624
Name:BRANAGIN, REGINA
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:BRANAGIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 HENLEY RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-6783
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 E MAIN SUITE A
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:IN
Practice Address - Zip Code:47353
Practice Address - Country:US
Practice Address - Phone:765-223-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018112A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist