Provider Demographics
NPI:1801225347
Name:BRADLEY, LISA (RPH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUARDIAN DR
Mailing Address - Street 2:
Mailing Address - City:WILDER
Mailing Address - State:KY
Mailing Address - Zip Code:41076-9714
Mailing Address - Country:US
Mailing Address - Phone:859-802-4302
Mailing Address - Fax:
Practice Address - Street 1:1601 MONMOUTH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:KY
Practice Address - Zip Code:41071-2634
Practice Address - Country:US
Practice Address - Phone:859-291-7343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010891183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist