Provider Demographics
NPI:1659658441
Name:BROBERG, JULIE LARSON (RPH)
Entity type:Individual
Prefix:MS
First Name:JULIE
Middle Name:LARSON
Last Name:BROBERG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 S PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2001
Mailing Address - Country:US
Mailing Address - Phone:719-561-4407
Mailing Address - Fax:719-561-1294
Practice Address - Street 1:1231 S PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2001
Practice Address - Country:US
Practice Address - Phone:719-561-4407
Practice Address - Fax:719-561-1294
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0021977183500000X
MN116056183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist