Provider Demographics
NPI:1649785098
Name:MCBROOM, ANGELA HOPE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:HOPE
Last Name:MCBROOM
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 1:1004 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5734
Mailing Address - Country:US
Mailing Address - Phone:318-322-8326
Mailing Address - Fax:
Practice Address - Street 1:1004 N 19TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5734
Practice Address - Country:US
Practice Address - Phone:318-322-8326
Practice Address - Fax:318-322-8326
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-07
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018189183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist