Provider Demographics
NPI:1720001464
Name:BROCKLEBANK, DONNA LEIGH (CPHT)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:LEIGH
Last Name:BROCKLEBANK
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-4214
Mailing Address - Country:US
Mailing Address - Phone:609-971-1032
Mailing Address - Fax:
Practice Address - Street 1:126 PARKER AVE
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-4214
Practice Address - Country:US
Practice Address - Phone:609-971-1032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3201-0105-0750-863183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician