Provider Demographics
NPI:1154092955
Name:BRADLEY, JERROD (PHARMD)
Entity Type:Individual
Prefix:
First Name:JERROD
Middle Name:
Last Name:BRADLEY
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 1:231 SUMMER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:MS
Mailing Address - Zip Code:38642-9132
Mailing Address - Country:US
Mailing Address - Phone:662-769-1319
Mailing Address - Fax:
Practice Address - Street 1:2461 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2005
Practice Address - Country:US
Practice Address - Phone:662-327-0079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-100258183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist