Provider Demographics
NPI:1750047148
Name:BROUILLARD, LAUREN (PHARMD,RPH)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:BROUILLARD
Suffix:
Gender:F
Credentials:PHARMD,RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 SURREY LN
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02745-3019
Mailing Address - Country:US
Mailing Address - Phone:508-441-7922
Mailing Address - Fax:
Practice Address - Street 1:784 MAIN RD
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:MA
Practice Address - Zip Code:02790-4341
Practice Address - Country:US
Practice Address - Phone:508-636-5957
Practice Address - Fax:508-636-6697
Is Sole Proprietor?:No
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH240068183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110021440AMedicaid