Provider Demographics
NPI:1730339565
Name:BROOKMAN, LESA F
Entity type:Individual
Prefix:MRS
First Name:LESA
Middle Name:F
Last Name:BROOKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 283
Mailing Address - Street 2:
Mailing Address - City:RICH CREEK
Mailing Address - State:VA
Mailing Address - Zip Code:24147-0283
Mailing Address - Country:US
Mailing Address - Phone:304-753-5008
Mailing Address - Fax:
Practice Address - Street 1:1561 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:RICH CREEK
Practice Address - State:VA
Practice Address - Zip Code:24147
Practice Address - Country:US
Practice Address - Phone:540-726-7911
Practice Address - Fax:540-726-7980
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011556183500000X
WVRP0005661183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist