Provider Demographics
NPI:1295029155
Name:BRODERSEN, MICHAEL J (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:BRODERSEN
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 1:17201 WRIGHT ST STE 203
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2042
Mailing Address - Country:US
Mailing Address - Phone:402-691-5102
Mailing Address - Fax:
Practice Address - Street 1:17201 WRIGHT ST STE 203
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2042
Practice Address - Country:US
Practice Address - Phone:402-691-5102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12870183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist