Provider Demographics
NPI:1023610433
Name:CASEBOLT, BRIAN ALAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:ALAN
Last Name:CASEBOLT
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 1:26713 IRA DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:64628-8391
Mailing Address - Country:US
Mailing Address - Phone:660-734-0989
Mailing Address - Fax:
Practice Address - Street 1:937 PARK CIRCLE DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:MO
Practice Address - Zip Code:64628-7920
Practice Address - Country:US
Practice Address - Phone:660-258-7404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO043946183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist