Healthcare Provider Details

I. General information

NPI: 1821308420
Provider Name (Legal Business Name): JUSTIN WYATT MALBROUGH CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2010
Last Update Date: 10/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10111 RICHMOND AVE
HOUSTON TX
77042-4215
US

IV. Provider business mailing address

10111 RICHMOND AVE.
HOUSTON TX
77042
US

V. Phone/Fax

Practice location:
  • Phone: 171-358-1708
  • Fax: 713-953-1925
Mailing address:
  • Phone: 171-358-1708
  • Fax: 713-953-1925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number181049
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: