Provider Demographics
NPI:1356365621
Name:BROCKWAY, MARY LOUISE (RPH)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:BROCKWAY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 PROSPECT DR
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301-5830
Mailing Address - Country:US
Mailing Address - Phone:406-234-0479
Mailing Address - Fax:
Practice Address - Street 1:210 S WINCHESTER AVE
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-4742
Practice Address - Country:US
Practice Address - Phone:406-874-5860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3157183500000X
WAPH00009669183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist