Provider Demographics
NPI:1992846182
Name:BRODERSON, ALAN (REG PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:
Last Name:BRODERSON
Suffix:
Gender:M
Credentials:REG PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4728
Mailing Address - Country:US
Mailing Address - Phone:201-921-4276
Mailing Address - Fax:201-568-2469
Practice Address - Street 1:136 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4728
Practice Address - Country:US
Practice Address - Phone:201-921-4276
Practice Address - Fax:201-568-2469
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025168183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY025168OtherLICENCE