Basic Information
| Provider Information | |||||||||
| NPI: | 1689074817 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROULLIRE | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | PHILLIPS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 ATLANTIC BLVD | ||||||||
| Address2: | |||||||||
| City: | NEPTUNE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322664000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042491725 | ||||||||
| FaxNumber: | 9042490292 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 ATLANTIC BLVD. | ||||||||
| Address2: | |||||||||
| City: | NEPTUNE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042491725 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2014 | ||||||||
| LastUpdateDate: | 12/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PS 51887 | FL | Y | Pharmacy Service Providers | Pharmacist | 183500000X | RPH028141 | GA | N | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | PS 51887 | 01 | FL | FLORIDA PHARMACIST LICENSE | OTHER | RPH028141 | 01 | GA | GA BOP | OTHER |