Provider Demographics
NPI:1346547643
Name:BRADLEY-WALL, REGINA (PHARMD)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:BRADLEY-WALL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 PELHAM RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3639
Mailing Address - Country:US
Mailing Address - Phone:864-234-6462
Mailing Address - Fax:864-234-6960
Practice Address - Street 1:902 PELHAM RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3639
Practice Address - Country:US
Practice Address - Phone:864-234-6462
Practice Address - Fax:864-234-6960
Is Sole Proprietor?:No
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10470183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist