Healthcare Provider Details

I. General information

NPI: 1609114743
Provider Name (Legal Business Name): NICHOLAS BRABHAM P.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2013
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N HIGHWAY 171
LAKE CHARLES LA
70611-5343
US

IV. Provider business mailing address

120 N HIGHWAY 171
LAKE CHARLES LA
70611-5343
US

V. Phone/Fax

Practice location:
  • Phone: 337-855-4848
  • Fax:
Mailing address:
  • Phone: 337-855-4848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0014744
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: