Provider Demographics
NPI:1871048868
Name:FAWSON, BRANDON SHAWN (RPH)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:SHAWN
Last Name:FAWSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6295 EL PALOMINO DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-6154
Mailing Address - Country:US
Mailing Address - Phone:951-533-3154
Mailing Address - Fax:
Practice Address - Street 1:6295 EL PALOMINO DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92509-6154
Practice Address - Country:US
Practice Address - Phone:951-533-3154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74779183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist