Provider Demographics
NPI:1942782354
Name:BECKER, BRAD
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:BECKER
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 1:846 N COLONY RD
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2410
Mailing Address - Country:US
Mailing Address - Phone:203-626-7765
Mailing Address - Fax:203-626-7767
Practice Address - Street 1:846 NORTH COLONY RD
Practice Address - Street 2:
Practice Address - City:WALINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492
Practice Address - Country:US
Practice Address - Phone:203-626-7765
Practice Address - Fax:203-626-7765
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0006005183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist