Healthcare Provider Details

I. General information

NPI: 1063580751
Provider Name (Legal Business Name): BRODY MAACK PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 NP AVE N
FARGO ND
58102-4835
US

IV. Provider business mailing address

523 PIPER ST
KINDRED ND
58051-4511
US

V. Phone/Fax

Practice location:
  • Phone: 701-271-6363
  • Fax:
Mailing address:
  • Phone: 701-306-9230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5068
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number118538
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberRPH5068
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: