Healthcare Provider Details

I. General information

NPI: 1700292919
Provider Name (Legal Business Name): MATTHEW DONOVAN BROOME PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 RICHBURG RD
GREAT FALLS SC
29055-8916
US

IV. Provider business mailing address

1601 SANDIFER BLVD
SENECA SC
29678-0905
US

V. Phone/Fax

Practice location:
  • Phone: 803-374-2480
  • Fax: 803-482-6533
Mailing address:
  • Phone: 864-885-0889
  • Fax: 803-482-6533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number35590
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: