Provider Demographics
NPI:1003193624
Name:MIRACLE, ANDREA BROOKE (PHARM D)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:BROOKE
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:NEW TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37825-6633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:915 N BROAD ST
Practice Address - Street 2:
Practice Address - City:NEW TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37825-6633
Practice Address - Country:US
Practice Address - Phone:423-626-5511
Practice Address - Fax:423-626-5544
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33135183500000X
KY014669183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist