=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497232532
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA BROCHU RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2018
-----------------------------------------------------
Last Update Date | 07/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24 STONE ST
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04330-5298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-623-4181
-----------------------------------------------------
Fax | 207-622-0760
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 163 MAXCYS MILL RD
-----------------------------------------------------
City | WINDSOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04363-3539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-215-5421
-----------------------------------------------------
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 | PR4987
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------