Provider Demographics
NPI:1174174684
Name:BACH, BRIAN ANTHONY (RPH)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ANTHONY
Last Name:BACH
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 1:1111 WATAUGA ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-2033
Mailing Address - Country:US
Mailing Address - Phone:314-363-9198
Mailing Address - Fax:
Practice Address - Street 1:4309 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1445
Practice Address - Country:US
Practice Address - Phone:919-231-2858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28685183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC28685OtherNCBOP LICENSE