Provider Demographics
NPI:1760866032
Name:HALLY, BROOKE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:
Last Name:HALLY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 N WHITLEY DR
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2129
Mailing Address - Country:US
Mailing Address - Phone:208-452-7075
Mailing Address - Fax:208-452-7446
Practice Address - Street 1:1620 N WHITLEY DR
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2129
Practice Address - Country:US
Practice Address - Phone:208-452-7075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7274183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist