Provider Demographics
NPI:1336525633
Name:MAHAN, J BRADLEY (RPH)
Entity Type:Individual
Prefix:
First Name:J BRADLEY
Middle Name:
Last Name:MAHAN
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 1:1477 STATE HIGHWAY 248
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-7477
Mailing Address - Country:US
Mailing Address - Phone:417-337-9529
Mailing Address - Fax:
Practice Address - Street 1:1477 STATE HIGHWAY 248
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-7477
Practice Address - Country:US
Practice Address - Phone:417-337-9529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006012347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2006012347OtherPHARMACIST