Provider Demographics
NPI:1902146368
Name:BRODSHO, KELLY LYNN (RPH)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:LYNN
Last Name:BRODSHO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-1420
Mailing Address - Country:US
Mailing Address - Phone:701-293-0221
Mailing Address - Fax:701-241-7944
Practice Address - Street 1:2800 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-1420
Practice Address - Country:US
Practice Address - Phone:701-293-0221
Practice Address - Fax:701-241-7944
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4301183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist