Provider Demographics
NPI:1669195558
Name:WIENER, BRADLEY SAMUAL (RPH)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:SAMUAL
Last Name:WIENER
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 1:12861 146TH PL N
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33418-7934
Mailing Address - Country:US
Mailing Address - Phone:561-870-3102
Mailing Address - Fax:
Practice Address - Street 1:3580 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:LIGHTHOUSE POINT
Practice Address - State:FL
Practice Address - Zip Code:33064-6608
Practice Address - Country:US
Practice Address - Phone:954-943-3244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55567183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist