Provider Demographics
NPI:1255356366
Name:PHELPS, BRAD ALAN (RPH)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:ALAN
Last Name:PHELPS
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 1:4210 N ROAN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1130
Mailing Address - Country:US
Mailing Address - Phone:423-262-0201
Mailing Address - Fax:423-262-0380
Practice Address - Street 1:4210 N ROAN ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1130
Practice Address - Country:US
Practice Address - Phone:423-262-0201
Practice Address - Fax:423-262-0380
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7774183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNBT4966288OtherDEA NUMBER