Provider Demographics
NPI:1508048620
Name:MADLIN, BROOK WADE (RPH)
Entity Type:Individual
Prefix:MR
First Name:BROOK
Middle Name:WADE
Last Name:MADLIN
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 1:130 DAYTON RD
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-3269
Mailing Address - Country:US
Mailing Address - Phone:315-261-4182
Mailing Address - Fax:
Practice Address - Street 1:19 MINER ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1231
Practice Address - Country:US
Practice Address - Phone:315-261-4182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047068183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist