Healthcare Provider Details

I. General information

NPI: 1093805202
Provider Name (Legal Business Name): MICHAEL RAYMOND BRODEUR PHARMD,CGP,FASCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 NEW SCOTLAND AVE ALBANY COLLEGE OF PHARMACY
ALBANY NY
12208-3425
US

IV. Provider business mailing address

32 SURREY MALL
SLINGERLANDS NY
12159-9650
US

V. Phone/Fax

Practice location:
  • Phone: 518-694-7386
  • Fax:
Mailing address:
  • Phone: 518-475-9282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number046286
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: