Provider Demographics
NPI:1730592783
Name:BRODE, MACKENZIE (PHARMD)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:BRODE
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 1:8501 FORT SMALLWOOD RD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-2607
Mailing Address - Country:US
Mailing Address - Phone:410-437-1149
Mailing Address - Fax:410-439-3043
Practice Address - Street 1:8501 FORT SMALLWOOD RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-2607
Practice Address - Country:US
Practice Address - Phone:410-437-1149
Practice Address - Fax:410-439-3043
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-07
Last Update Date:2014-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21649183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist