Provider Demographics
NPI:1720445653
Name:COFFELT, BROOKE F (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:F
Last Name:COFFELT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:BROOKE
Other - Middle Name:F
Other - Last Name:EMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:1807 EDNA DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3724
Mailing Address - Country:US
Mailing Address - Phone:662-415-0576
Mailing Address - Fax:
Practice Address - Street 1:1807 EDNA DR
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3724
Practice Address - Country:US
Practice Address - Phone:662-415-0576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-0105191835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy