Provider Demographics
NPI:1043779796
Name:BRODNICKI, SAMANTHA (RPH)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BRODNICKI
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 1:710 LONG COVE RD
Mailing Address - Street 2:
Mailing Address - City:GALES FERRY
Mailing Address - State:CT
Mailing Address - Zip Code:06335-2005
Mailing Address - Country:US
Mailing Address - Phone:860-884-4486
Mailing Address - Fax:
Practice Address - Street 1:915 POQUONNOCK RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4257
Practice Address - Country:US
Practice Address - Phone:860-446-0912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0014068183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist