Provider Demographics
NPI:1649317769
Name:BRADLEY, RICHARD DARRELL (RPH)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:DARRELL
Last Name:BRADLEY
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:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:STATE LINE
Mailing Address - State:MS
Mailing Address - Zip Code:39362-0159
Mailing Address - Country:US
Mailing Address - Phone:601-848-7866
Mailing Address - Fax:601-848-7866
Practice Address - Street 1:194 MAIN ST.
Practice Address - Street 2:
Practice Address - City:STATE LINE
Practice Address - State:MS
Practice Address - Zip Code:39362-0159
Practice Address - Country:US
Practice Address - Phone:601-848-7866
Practice Address - Fax:601-848-7866
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-6230183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00094081Medicaid