Provider Demographics
NPI:1336481423
Name:VAN BUREN, BRADLEY J
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:VAN BUREN
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 1:408 DOWNING DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-8706
Mailing Address - Country:US
Mailing Address - Phone:757-482-2559
Mailing Address - Fax:
Practice Address - Street 1:748 INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6206
Practice Address - Country:US
Practice Address - Phone:757-497-1963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202006436183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist