Provider Demographics
NPI:1881768307
Name:BRENNCORP INC
Entity type:Organization
Organization Name:BRENNCORP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-739-2424
Mailing Address - Street 1:2152 AIRPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36606-1756
Mailing Address - Country:US
Mailing Address - Phone:251-479-2424
Mailing Address - Fax:251-479-5234
Practice Address - Street 1:2152 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-1756
Practice Address - Country:US
Practice Address - Phone:251-479-2424
Practice Address - Fax:251-479-5234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1096683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0119366OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AL100002231Medicaid