Provider Demographics
NPI:1114340379
Name:WENDEROTH, BRADLEY RAY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:RAY
Last Name:WENDEROTH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14006 OTSEGO ST
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-1225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 SAN PABLO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033
Practice Address - Country:US
Practice Address - Phone:323-865-9974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-23
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66409183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist