=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356851448
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BROOKE NIELSEN TABONE PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2017
-----------------------------------------------------
Last Update Date | 10/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 317 E 100 N STE 4
-----------------------------------------------------
City | PRICE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84501-2504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-637-6337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 WOODHILL DR
-----------------------------------------------------
City | PRICE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84501-2436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-650-3848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 333267-1701
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------