Provider Demographics
NPI:1942489281
Name:BRADLEY, JASON TODD (RPH)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:TODD
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 1:449 POINT AU ROCHE RD
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-5465
Mailing Address - Country:US
Mailing Address - Phone:518-260-6704
Mailing Address - Fax:
Practice Address - Street 1:7550 COURT STREET
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NY
Practice Address - Zip Code:12932
Practice Address - Country:US
Practice Address - Phone:518-873-6441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-02
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042979183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist