Provider Demographics
NPI:1407342447
Name:BAZO, BRAD (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:BAZO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:IOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66749-2533
Mailing Address - Country:US
Mailing Address - Phone:620-228-3349
Mailing Address - Fax:
Practice Address - Street 1:2051 N STATE ST
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:KS
Practice Address - Zip Code:66749
Practice Address - Country:US
Practice Address - Phone:620-380-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-106216183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist