Provider Demographics
NPI:1376146845
Name:BROUSSARD, SHAWN D (RPH)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:D
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 SPRING HILL DR
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-6032
Mailing Address - Country:US
Mailing Address - Phone:281-466-5819
Mailing Address - Fax:
Practice Address - Street 1:608 SPRING HILL DR
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77386-6032
Practice Address - Country:US
Practice Address - Phone:281-466-5819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36175183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist