Provider Demographics
NPI:1790127918
Name:BRADLEY, IVAN L (RPH)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:L
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 1:519 HEMINGWAY CT
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-6782
Mailing Address - Country:US
Mailing Address - Phone:386-216-9598
Mailing Address - Fax:
Practice Address - Street 1:519 HEMINGWAY CT
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-6782
Practice Address - Country:US
Practice Address - Phone:386-216-9598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-30
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0023023183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$OtherSOCIAL SECURITY NUMBER