Provider Demographics
NPI:1376655969
Name:BRADFORD, WALLACE EARL (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:EARL
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 HUNTERS CT
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:TX
Mailing Address - Zip Code:77657-7317
Mailing Address - Country:US
Mailing Address - Phone:409-755-2033
Mailing Address - Fax:
Practice Address - Street 1:3420 VETERANS CIR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-2552
Practice Address - Country:US
Practice Address - Phone:409-981-8570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36667183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist