Provider Demographics
NPI:1447545207
Name:MUTRUX, BRANDON KEITH (PHARMD)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:KEITH
Last Name:MUTRUX
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 SPORTS ARENA BLVD
Mailing Address - Street 2:T-0201
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3245 SPORTS ARENA BLVD
Practice Address - Street 2:T-0201
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4529
Practice Address - Country:US
Practice Address - Phone:619-471-0030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61583183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist