Provider Demographics
NPI:1578689899
Name:BROCKETT, KEVIN DALE (BS PHARMACY)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DALE
Last Name:BROCKETT
Suffix:
Gender:M
Credentials:BS PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 S POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80224-2527
Mailing Address - Country:US
Mailing Address - Phone:720-530-7953
Mailing Address - Fax:
Practice Address - Street 1:1677 S HAVANA ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-5007
Practice Address - Country:US
Practice Address - Phone:303-481-2291
Practice Address - Fax:303-481-2283
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15268183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist