Healthcare Provider Details

I. General information

NPI: 1073091070
Provider Name (Legal Business Name): BRODERICK ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 E 9TH ST
ADA OK
74820-3807
US

IV. Provider business mailing address

711 E 9TH ST
ADA OK
74820-3807
US

V. Phone/Fax

Practice location:
  • Phone: 580-332-3344
  • Fax: 580-332-3616
Mailing address:
  • Phone: 580-332-3344
  • Fax: 580-332-3616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number23-8228
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200803550A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name: ZACK BRODERICK
Title or Position: PHARMACIST/OWER
Credential: PHARMD
Phone: 580-332-3344