Provider Demographics
NPI:1174041701
Name:COLEMAN, BRADLEY W
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:W
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3917 UPOLO LANE
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119
Mailing Address - Country:US
Mailing Address - Phone:239-595-3438
Mailing Address - Fax:
Practice Address - Street 1:3917 UPOLO LANE
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119
Practice Address - Country:US
Practice Address - Phone:239-595-3438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-04
Last Update Date:2017-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0027224183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC455-079-67-141-0OtherDRIVERS LICENSE