Provider Demographics
NPI:1356744395
Name:BROCKHAUSEN, KURT
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:
Last Name:BROCKHAUSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2290 KING AVE W
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-7415
Mailing Address - Country:US
Mailing Address - Phone:406-652-8556
Mailing Address - Fax:406-656-4069
Practice Address - Street 1:2290 KING AVE WEST
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102
Practice Address - Country:US
Practice Address - Phone:406-652-8556
Practice Address - Fax:406-656-4069
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-05
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT33621835P0018X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT3362OtherMT LIC#