Provider Demographics
NPI:1093805202
Name:BRODEUR, MICHAEL RAYMOND (PHARMD,CGP,FASCP)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RAYMOND
Last Name:BRODEUR
Suffix:
Gender:M
Credentials:PHARMD,CGP,FASCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 SURREY MALL
Mailing Address - Street 2:
Mailing Address - City:SLINGERLANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12159-9650
Mailing Address - Country:US
Mailing Address - Phone:518-475-9282
Mailing Address - Fax:
Practice Address - Street 1:106 NEW SCOTLAND AVE
Practice Address - Street 2:ALBANY COLLEGE OF PHARMACY
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3425
Practice Address - Country:US
Practice Address - Phone:518-694-7386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0462861835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric