Provider Demographics
NPI:1457355836
Name:BRADFORD, JAMES RANDOLPH (DPH)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:RANDOLPH
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:RANDOLPH
Other - Last Name:BRADFORD
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:104 HUDGINS ST
Mailing Address - Street 2:
Mailing Address - City:ESTILL SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37330-3027
Mailing Address - Country:US
Mailing Address - Phone:931-649-5050
Mailing Address - Fax:931-649-3148
Practice Address - Street 1:104 HUDGINS ST
Practice Address - Street 2:
Practice Address - City:ESTILL SPRINGS
Practice Address - State:TN
Practice Address - Zip Code:37330-3027
Practice Address - Country:US
Practice Address - Phone:931-649-5050
Practice Address - Fax:931-649-3148
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9611183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452213Medicaid
TN1170240001Medicare NSC