Provider Demographics
NPI:1245768845
Name:BRADLEY, COREY ALEXANDER (RPH)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:ALEXANDER
Last Name:BRADLEY
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 1:1306 CHICO ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-4000
Mailing Address - Country:US
Mailing Address - Phone:575-302-6754
Mailing Address - Fax:
Practice Address - Street 1:2101 NORTHERN BLVD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4727
Practice Address - Country:US
Practice Address - Phone:505-217-3980
Practice Address - Fax:505-217-3980
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00008702183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist