Provider Demographics
NPI:1750097762
Name:BRADFORD, JUSTIN ROBERT (PHARMD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ROBERT
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:PHARMD
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 64
Mailing Address - Street 2:
Mailing Address - City:MATEWAN
Mailing Address - State:WV
Mailing Address - Zip Code:25678-0064
Mailing Address - Country:US
Mailing Address - Phone:606-471-9872
Mailing Address - Fax:304-239-3468
Practice Address - Street 1:164 HOLDEN RD
Practice Address - Street 2:
Practice Address - City:MOUNT GAY
Practice Address - State:WV
Practice Address - Zip Code:25637-1126
Practice Address - Country:US
Practice Address - Phone:304-239-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0013159183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist