Provider Demographics
NPI:1457951543
Name:NELSON, BRADLEY JOHN (RPH)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JOHN
Last Name:NELSON
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 1:2504 CLUBHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55041-4919
Mailing Address - Country:US
Mailing Address - Phone:507-460-2310
Mailing Address - Fax:
Practice Address - Street 1:500 CROSSROADS DR SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-2180
Practice Address - Country:US
Practice Address - Phone:507-280-9441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115053183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist