Provider Demographics
NPI:1447851761
Name:BROCKETT, CHRISTINE MARIE (RPH)
Entity type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:MARIE
Last Name:BROCKETT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 N CASS ST
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-9404
Mailing Address - Country:US
Mailing Address - Phone:260-563-4033
Mailing Address - Fax:260-563-3423
Practice Address - Street 1:1601 N CASS ST
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-9404
Practice Address - Country:US
Practice Address - Phone:260-563-4033
Practice Address - Fax:260-563-3423
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024702A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist