Provider Demographics
NPI:1477952257
Name:BROOM, CRAIG
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:BROOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23102 E APPLEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-9585
Mailing Address - Country:US
Mailing Address - Phone:509-928-8738
Mailing Address - Fax:
Practice Address - Street 1:23102 E APPLEWAY AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-9585
Practice Address - Country:US
Practice Address - Phone:509-928-8738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 00042759183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist