Provider Demographics
NPI:1295018240
Name:BROCKMAN, KATHY
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 LIME KILN LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-3425
Mailing Address - Country:US
Mailing Address - Phone:502-425-6121
Mailing Address - Fax:502-326-0101
Practice Address - Street 1:2420 LIME KILN LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-3425
Practice Address - Country:US
Practice Address - Phone:502-425-6121
Practice Address - Fax:502-326-0101
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010895183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist