Healthcare Provider Details

I. General information

NPI: 1356365621
Provider Name (Legal Business Name): MARY LOUISE BROCKWAY RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S WINCHESTER AVE
MILES CITY MT
59301-4742
US

IV. Provider business mailing address

117 PROSPECT DR
MILES CITY MT
59301-5830
US

V. Phone/Fax

Practice location:
  • Phone: 406-874-5860
  • Fax:
Mailing address:
  • Phone: 406-234-0479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3157
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00009669
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: