Provider Demographics
NPI:1508145996
Name:BROUSSARD, MARLON JOSEPH (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:MARLON
Middle Name:JOSEPH
Last Name:BROUSSARD
Suffix:
Gender:M
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 1:501 N GRAHAM ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1654
Mailing Address - Country:US
Mailing Address - Phone:503-413-4225
Mailing Address - Fax:503-413-4515
Practice Address - Street 1:501 N GRAHAM ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1654
Practice Address - Country:US
Practice Address - Phone:503-413-4225
Practice Address - Fax:503-413-4515
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0011134183500000X
OR111341835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist