Provider Demographics
NPI:1316559990
Name:BRODERICK, MITCHELL JAMES (RPH)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:JAMES
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4440 W 95TH ST STE 201P
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2600
Mailing Address - Country:US
Mailing Address - Phone:708-857-1935
Mailing Address - Fax:708-857-1965
Practice Address - Street 1:4440 W 95TH ST STE 201P
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2600
Practice Address - Country:US
Practice Address - Phone:708-857-1935
Practice Address - Fax:708-857-1965
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.300912183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist