Provider Demographics
NPI:1942804224
Name:BRODERICK, RICHARD FOSTER
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:FOSTER
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3195 LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45208-2946
Mailing Address - Country:US
Mailing Address - Phone:513-321-2470
Mailing Address - Fax:
Practice Address - Street 1:3195 LINWOOD AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45208-2946
Practice Address - Country:US
Practice Address - Phone:513-321-2470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-26
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH033199201835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care