Provider Demographics
NPI:1659446540
Name:BRODETSKY, KELLY E (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:E
Last Name:BRODETSKY
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:PO BOX 904
Mailing Address - Street 2:
Mailing Address - City:MENDOCINO
Mailing Address - State:CA
Mailing Address - Zip Code:95460-0904
Mailing Address - Country:US
Mailing Address - Phone:707-937-4800
Mailing Address - Fax:707-937-5800
Practice Address - Street 1:10501 LANSING STREET
Practice Address - Street 2:#904
Practice Address - City:MENDOCINO
Practice Address - State:CA
Practice Address - Zip Code:95460-0904
Practice Address - Country:US
Practice Address - Phone:707-937-4800
Practice Address - Fax:707-937-5800
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY45989183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY45989OtherSTATE LICENSE NUMBER
CA412046786OtherFEDERAL TAX ID
CA0582292OtherNCPDP NUMBER
CAPHA459890Medicaid
CAPHA459890Medicaid
CAPHY45989OtherSTATE LICENSE NUMBER