Provider Demographics
NPI:1184237562
Name:RICHARDSON, BRAD
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:RICHARDSON
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 1:1191 WESTOWNE DR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2176
Mailing Address - Country:US
Mailing Address - Phone:920-725-3152
Mailing Address - Fax:
Practice Address - Street 1:1191 WESTOWNE DR
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2176
Practice Address - Country:US
Practice Address - Phone:920-725-3152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20665-40183500000X
NV20124183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist