Provider Demographics
NPI:1942800453
Name:AUTEN, BRADLEY ALAN
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ALAN
Last Name:AUTEN
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 1:7 DOWNING PL
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1563
Mailing Address - Country:US
Mailing Address - Phone:618-806-4744
Mailing Address - Fax:
Practice Address - Street 1:2591 12TH ST
Practice Address - Street 2:
Practice Address - City:CARLYLE
Practice Address - State:IL
Practice Address - Zip Code:62231-6499
Practice Address - Country:US
Practice Address - Phone:618-594-3658
Practice Address - Fax:618-594-3670
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051038194183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist