Provider Demographics
NPI:1235438029
Name:SULLIVAN, BRADLEY DUANE
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DUANE
Last Name:SULLIVAN
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 1:415 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1701
Mailing Address - Country:US
Mailing Address - Phone:304-329-2212
Mailing Address - Fax:
Practice Address - Street 1:415 E MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1701
Practice Address - Country:US
Practice Address - Phone:304-329-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-20
Last Update Date:2011-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007283183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist