Healthcare Provider Details

I. General information

NPI: 1134115678
Provider Name (Legal Business Name): HARLEY JOHN BROTHERTON II PHARMD.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 03/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 SUNNYVIEW LN
KALISPELL MT
59901-3129
US

IV. Provider business mailing address

145 BUFFALO STAGE
KALISPELL MT
59901-2780
US

V. Phone/Fax

Practice location:
  • Phone: 406-752-1761
  • Fax:
Mailing address:
  • Phone: 406-257-3258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number16649
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5888
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number41135
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: