Healthcare Provider Details

I. General information

NPI: 1356744395
Provider Name (Legal Business Name): KURT BROCKHAUSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2014
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2290 KING AVE WEST
BILLINGS MT
59102
US

IV. Provider business mailing address

2290 KING AVE W
BILLINGS MT
59102-7415
US

V. Phone/Fax

Practice location:
  • Phone: 406-652-8556
  • Fax: 406-656-4069
Mailing address:
  • Phone: 406-652-8556
  • Fax: 406-656-4069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3362
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number3362
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: