Provider Demographics
NPI:1912118316
Name:BRODERICK, REBECCA S (PHARMD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:S
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2559 N GREENVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2028
Mailing Address - Country:US
Mailing Address - Phone:773-879-9227
Mailing Address - Fax:
Practice Address - Street 1:3030 CULLERTON ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN PARK
Practice Address - State:IL
Practice Address - Zip Code:60131-2205
Practice Address - Country:US
Practice Address - Phone:847-916-4365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist