Provider Demographics
NPI:1265523955
Name:CRUMP, BRADLEY ALAN
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ALAN
Last Name:CRUMP
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 1:1616 E PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1431
Mailing Address - Country:US
Mailing Address - Phone:765-651-9896
Mailing Address - Fax:
Practice Address - Street 1:124 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRMOUNT
Practice Address - State:IN
Practice Address - Zip Code:46928-1654
Practice Address - Country:US
Practice Address - Phone:765-948-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015701A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist