Provider Demographics
NPI:1720363799
Name:BROCKWAY, JULIE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:BROCKWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 MAY ST
Mailing Address - Street 2:APT 9
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906-5296
Mailing Address - Country:US
Mailing Address - Phone:586-219-2245
Mailing Address - Fax:
Practice Address - Street 1:812 E SAGINAW HWY
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-8410
Practice Address - Country:US
Practice Address - Phone:517-627-1240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302038636183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist