Provider Demographics
NPI:1902354723
Name:BLACK, BROOKE (PHARMD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12862 OAK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HOLTON
Mailing Address - State:KS
Mailing Address - Zip Code:66436-8064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:427 S ARIZONA AVE
Practice Address - Street 2:
Practice Address - City:HOLTON
Practice Address - State:KS
Practice Address - Zip Code:66436-1217
Practice Address - Country:US
Practice Address - Phone:785-364-4619
Practice Address - Fax:785-364-2183
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14633183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist