Provider Demographics
NPI:1164822995
Name:BRADLEY, PAUL TUCKER (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:TUCKER
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 S 180 E
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84335-1669
Mailing Address - Country:US
Mailing Address - Phone:540-394-0318
Mailing Address - Fax:
Practice Address - Street 1:1550 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1918
Practice Address - Country:US
Practice Address - Phone:435-753-0330
Practice Address - Fax:435-753-1969
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8368522-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist