Provider Demographics
NPI:1295089662
Name:BROCKETT, TILFORD A JR
Entity type:Individual
Prefix:MR
First Name:TILFORD
Middle Name:A
Last Name:BROCKETT
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12647 OLIVE BLVD
Mailing Address - Street 2:STE 600
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6393
Mailing Address - Country:US
Mailing Address - Phone:314-744-4107
Mailing Address - Fax:877-685-9866
Practice Address - Street 1:12647 OLIVE BLVD
Practice Address - Street 2:STE 600
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6393
Practice Address - Country:US
Practice Address - Phone:314-744-4107
Practice Address - Fax:877-685-9866
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15314183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist