Provider Demographics
NPI:1558721324
Name:BRADLEY, MARION (RPH)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:BEACON FALLS
Mailing Address - State:CT
Mailing Address - Zip Code:06403-0218
Mailing Address - Country:US
Mailing Address - Phone:203-729-4567
Mailing Address - Fax:203-729-4573
Practice Address - Street 1:20 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BEACON FALLS
Practice Address - State:CT
Practice Address - Zip Code:06403-1131
Practice Address - Country:US
Practice Address - Phone:203-729-4567
Practice Address - Fax:203-729-4573
Is Sole Proprietor?:No
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0006934183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004253548Medicaid