Provider Demographics
NPI:1619340049
Name:BAVER, BRADLEY DAVID (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DAVID
Last Name:BAVER
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4744 S HIGHWAY 95
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-9377
Mailing Address - Country:US
Mailing Address - Phone:928-763-6822
Mailing Address - Fax:
Practice Address - Street 1:2092 PALO VERDE BLVD S
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-4810
Practice Address - Country:US
Practice Address - Phone:610-207-0210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-06
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS017499183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist