Provider Demographics
NPI:1922368455
Name:DEBRUIN, ADAM SR
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:DEBRUIN
Suffix:SR
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 1:842 N WESTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-5788
Mailing Address - Country:US
Mailing Address - Phone:877-667-4689
Mailing Address - Fax:
Practice Address - Street 1:842 N WESTHILL BLVD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-5788
Practice Address - Country:US
Practice Address - Phone:877-667-4689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-17
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS019033183500000X
FLPS24518183500000X
IL051.037489183500000X
VA0202210659183500000X
WI12294-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist