Provider Demographics
NPI:1699361303
Name:SMITH, ALTON BRADLEY
Entity Type:Individual
Prefix:
First Name:ALTON
Middle Name:BRADLEY
Last Name:SMITH
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 1:2303 HIGHWAY 59 NORTH BYP
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TX
Mailing Address - Zip Code:77327-2883
Mailing Address - Country:US
Mailing Address - Phone:281-622-5590
Mailing Address - Fax:
Practice Address - Street 1:603 E HOUSTON ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TX
Practice Address - Zip Code:77327-4628
Practice Address - Country:US
Practice Address - Phone:281-592-5257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22381183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist