Provider Demographics
NPI:1811279599
Name:BROM, M ANTHONY (RPH)
Entity type:Individual
Prefix:
First Name:M ANTHONY
Middle Name:
Last Name:BROM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:TONY
Other - Middle Name:
Other - Last Name:BROM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:1695 N SUNRISE WAY
Mailing Address - Street 2:WALGREENS ONSITE PHARMACY
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-3701
Mailing Address - Country:US
Mailing Address - Phone:760-325-9370
Mailing Address - Fax:760-325-9374
Practice Address - Street 1:1695 N SUNRISE WAY
Practice Address - Street 2:WALGREENS ONSITE PHARMACY
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-3701
Practice Address - Country:US
Practice Address - Phone:760-325-9370
Practice Address - Fax:760-325-9374
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55503183500000X
MN113190183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist