Provider Demographics
NPI:1609271139
Name:HOUSTON, BRENT
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:HOUSTON
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 1:1424 W BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1118
Mailing Address - Country:US
Mailing Address - Phone:480-897-9774
Mailing Address - Fax:
Practice Address - Street 1:1424 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1118
Practice Address - Country:US
Practice Address - Phone:480-897-9774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS020598183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist