Provider Demographics
NPI:1104149434
Name:BROSKY, STEPHEN (RPH)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:BROSKY
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 1:213 AMITY AVE
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518-1034
Mailing Address - Country:US
Mailing Address - Phone:570-821-6190
Mailing Address - Fax:570-821-6192
Practice Address - Street 1:213 AMITY AVE
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518-1034
Practice Address - Country:US
Practice Address - Phone:570-821-6190
Practice Address - Fax:570-821-6192
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-01
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP040035L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP040035LOtherSTATE LICENSE RP-040035L