Provider Demographics
NPI:1528577079
Name:TUCKER, BRADY RAYMOND
Entity Type:Individual
Prefix:DR
First Name:BRADY
Middle Name:RAYMOND
Last Name:TUCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5123 E HERMOSA DR
Mailing Address - Street 2:
Mailing Address - City:CORNVILLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86325-5149
Mailing Address - Country:US
Mailing Address - Phone:518-223-5998
Mailing Address - Fax:
Practice Address - Street 1:20 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-5805
Practice Address - Country:US
Practice Address - Phone:928-282-8569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2022-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS023002183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist