Provider Demographics
NPI:1487315024
Name:HEALAN, BRENTON MICHAEL (PHARMACY TECHNICIAN)
Entity type:Individual
Prefix:MR
First Name:BRENTON
Middle Name:MICHAEL
Last Name:HEALAN
Suffix:
Gender:M
Credentials:PHARMACY TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 N CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:KALKASKA
Mailing Address - State:MI
Mailing Address - Zip Code:49646-8061
Mailing Address - Country:US
Mailing Address - Phone:231-258-2081
Mailing Address - Fax:231-258-5883
Practice Address - Street 1:13916 S WEST BAY SHORE DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-6297
Practice Address - Country:US
Practice Address - Phone:231-946-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303039060183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician