Provider Demographics
NPI:1255600102
Name:BROSTROM, BRADY MARK (RP)
Entity type:Individual
Prefix:MR
First Name:BRADY
Middle Name:MARK
Last Name:BROSTROM
Suffix:
Gender:M
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7045 O ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2426
Mailing Address - Country:US
Mailing Address - Phone:402-484-8222
Mailing Address - Fax:402-484-7451
Practice Address - Street 1:7045 O ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-2426
Practice Address - Country:US
Practice Address - Phone:402-484-8222
Practice Address - Fax:402-484-7451
Is Sole Proprietor?:No
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8659183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025934000Medicaid