Provider Demographics
NPI:1427190222
Name:BRADFORD PHARMACY
Entity Type:Organization
Organization Name:BRADFORD PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:MS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HOY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:309-897-2701
Mailing Address - Street 1:102 W MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:IL
Practice Address - Zip Code:61421
Practice Address - Country:US
Practice Address - Phone:309-897-2701
Practice Address - Fax:309-897-8190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054004928183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1410543OtherNCPDP
IL=========Medicaid
IL1410543OtherNCPDP