Provider Demographics
NPI:1255760179
Name:BRADLEY, BRENT (PD)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 CLUB MANOR
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113
Mailing Address - Country:US
Mailing Address - Phone:501-803-9400
Mailing Address - Fax:501-803-9441
Practice Address - Street 1:1900 CLUB MANOR
Practice Address - Street 2:
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113
Practice Address - Country:US
Practice Address - Phone:501-803-9400
Practice Address - Fax:501-803-9441
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR10677Medicare UPIN