Provider Demographics
NPI:1952647943
Name:BRADFORD PHARMACY LLC
Entity Type:Organization
Organization Name:BRADFORD PHARMACY LLC
Other - Org Name:BRADFORD FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:901-355-5733
Mailing Address - Street 1:1500 HIGHWAY 51 S
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38019-3212
Mailing Address - Country:US
Mailing Address - Phone:901-475-6300
Mailing Address - Fax:901-475-1888
Practice Address - Street 1:1500 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-3212
Practice Address - Country:US
Practice Address - Phone:901-475-6300
Practice Address - Fax:901-475-1888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-19
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN51453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138848OtherPK
TN7493170001Medicare NSC