Provider Demographics
NPI:1992037568
Name:BRODERICK, CHARLES DAVID (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DAVID
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 1:1953 W DESERT HIGHLANDS DR
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85737-7037
Mailing Address - Country:US
Mailing Address - Phone:206-409-3730
Mailing Address - Fax:
Practice Address - Street 1:10405 N LA CANADA DR
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85737-6945
Practice Address - Country:US
Practice Address - Phone:520-297-5934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 00010245183500000X
AZS015293183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist