Provider Demographics
NPI:1407945058
Name:BRADFORD DRUGSTORE, INC.
Entity Type:Organization
Organization Name:BRADFORD DRUGSTORE, INC.
Other - Org Name:BRADFORD DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWSTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-748-3100
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:CEDARTOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30125-0126
Mailing Address - Country:US
Mailing Address - Phone:770-748-3100
Mailing Address - Fax:770-748-0379
Practice Address - Street 1:500 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2302
Practice Address - Country:US
Practice Address - Phone:770-748-3100
Practice Address - Fax:770-748-0379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0047483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2012100OtherPK
1107499OtherNCPDP PROVIDER IDENTIFICATION NUMBER
GA5427220001Medicare NSC