Provider Demographics
NPI:1669571246
Name:EUSTACE, BRAD ERIC (RPH)
Entity type:Individual
Prefix:MR
First Name:BRAD
Middle Name:ERIC
Last Name:EUSTACE
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 1:908 NILES AVE
Mailing Address - Street 2:
Mailing Address - City:KINSLEY
Mailing Address - State:KS
Mailing Address - Zip Code:67547-1418
Mailing Address - Country:US
Mailing Address - Phone:620-659-2481
Mailing Address - Fax:620-659-2252
Practice Address - Street 1:207 E 6TH ST
Practice Address - Street 2:
Practice Address - City:KINSLEY
Practice Address - State:KS
Practice Address - Zip Code:67547-1109
Practice Address - Country:US
Practice Address - Phone:620-659-2481
Practice Address - Fax:620-659-2252
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9455183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS9455OtherPHARMACIST LICENSE