Provider Demographics
NPI:1962485847
Name:BRADDOCK, DAVID S (RPH)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:S
Last Name:BRADDOCK
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:P.O. BOX 582
Mailing Address - Street 2:119 N. MARKET ST.
Mailing Address - City:SHREVE
Mailing Address - State:OH
Mailing Address - Zip Code:44676
Mailing Address - Country:US
Mailing Address - Phone:330-567-2823
Mailing Address - Fax:330-567-2660
Practice Address - Street 1:119 N. MARKET ST.
Practice Address - Street 2:
Practice Address - City:SHREVE
Practice Address - State:OH
Practice Address - Zip Code:44676
Practice Address - Country:US
Practice Address - Phone:330-567-2823
Practice Address - Fax:330-567-2660
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-12838183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0665990Medicaid
OH0665990Medicaid