Provider Demographics
NPI:1508466525
Name:BRADFORD, ALLYSSA NICCOLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:ALLYSSA
Middle Name:NICCOLE
Last Name:BRADFORD
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 1:735 OAKWOOD RD APT 5
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-1761
Mailing Address - Country:US
Mailing Address - Phone:304-763-1820
Mailing Address - Fax:
Practice Address - Street 1:2700 MOUNTAINEER BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-9442
Practice Address - Country:US
Practice Address - Phone:304-746-1725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0011960183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist