Provider Demographics
NPI:1083109771
Name:BROCKER, JONATHAN BRADLEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:BRADLEY
Last Name:BROCKER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16100 W 65TH ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66217-9301
Mailing Address - Country:US
Mailing Address - Phone:913-268-3545
Mailing Address - Fax:913-268-3828
Practice Address - Street 1:16100 W 65TH ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66217-9301
Practice Address - Country:US
Practice Address - Phone:913-268-3545
Practice Address - Fax:913-268-3828
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-134281835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy