Provider Demographics
NPI:1477846434
Name:BRADLEY, MARY D (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:D
Last Name:BRADLEY
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 1:3471 W CENTURY BLVD
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90303-1218
Mailing Address - Country:US
Mailing Address - Phone:310-677-5937
Mailing Address - Fax:310-677-5937
Practice Address - Street 1:3471 W CENTURY BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90303-1218
Practice Address - Country:US
Practice Address - Phone:310-677-5937
Practice Address - Fax:310-677-5937
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57492183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA410215170Medicaid