Provider Demographics
NPI:1912374505
Name:BRADY, ALPHONSUS M
Entity Type:Individual
Prefix:
First Name:ALPHONSUS M
Middle Name:
Last Name:BRADY
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 1:2510 EAST WASHINGTON ST
Mailing Address - Street 2:APT #13
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704
Mailing Address - Country:US
Mailing Address - Phone:309-660-4210
Mailing Address - Fax:
Practice Address - Street 1:2510 E WASHINGTON ST
Practice Address - Street 2:APT #13
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4447
Practice Address - Country:US
Practice Address - Phone:309-660-4210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051296175183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist