Provider Demographics
NPI:1821308420
Name:MALBROUGH, JUSTIN WYATT (CPHT)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:WYATT
Last Name:MALBROUGH
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10111 RICHMOND AVE.
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042
Mailing Address - Country:US
Mailing Address - Phone:171-358-1708
Mailing Address - Fax:713-953-1925
Practice Address - Street 1:10111 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-4215
Practice Address - Country:US
Practice Address - Phone:171-358-1708
Practice Address - Fax:713-953-1925
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX181049183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician