Provider Demographics
NPI:1619173911
Name:NELSON, JON BRADLEY (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:BRADLEY
Last Name:NELSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6422 DEERFOOT CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-3612
Mailing Address - Country:US
Mailing Address - Phone:205-655-3663
Mailing Address - Fax:
Practice Address - Street 1:2100 16TH AVE S STE 112
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-5021
Practice Address - Country:US
Practice Address - Phone:205-380-6170
Practice Address - Fax:205-380-6172
Is Sole Proprietor?:No
Enumeration Date:2007-06-23
Last Update Date:2011-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15501183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist