Provider Demographics
NPI:1154721603
Name:BROUSSARD, MOLLY EILEEN
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:EILEEN
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:EILEEN
Other - Last Name:HANNIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:108 LINWOOD LN
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-8111
Mailing Address - Country:US
Mailing Address - Phone:907-714-1621
Mailing Address - Fax:
Practice Address - Street 1:299 N BINKLEY ST
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7523
Practice Address - Country:US
Practice Address - Phone:907-262-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2025-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK113742183500000X
CA71279183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist