Provider Demographics
NPI:1225045578
Name:PETERSON, BRADLEY E (RPH)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:E
Last Name:PETERSON
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 1:184 VALLETTE ST
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-6224
Mailing Address - Country:US
Mailing Address - Phone:401-273-7100
Mailing Address - Fax:401-457-3372
Practice Address - Street 1:184 VALLETTE ST
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6224
Practice Address - Country:US
Practice Address - Phone:401-273-7100
Practice Address - Fax:401-457-3372
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRPH028091835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy