Provider Demographics
NPI:1477223162
Name:BROKAW, STEPHANIE SUZANNE (PHARMD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SUZANNE
Last Name:BROKAW
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 S LONGMORE APT 170
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-4353
Mailing Address - Country:US
Mailing Address - Phone:419-565-5122
Mailing Address - Fax:
Practice Address - Street 1:865 N ARIZOLA RD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-6011
Practice Address - Country:US
Practice Address - Phone:520-381-0395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03441005183500000X
AZS025407183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist