Provider Demographics
NPI:1801062187
Name:BRADLEY AND BRANDY NEIGHBORHOOD PHARMACY LLC
Entity type:Organization
Organization Name:BRADLEY AND BRANDY NEIGHBORHOOD PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PIC
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:770-877-3005
Mailing Address - Street 1:11 LEGACY WAY
Mailing Address - Street 2:STE E
Mailing Address - City:ADAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30103-2464
Mailing Address - Country:US
Mailing Address - Phone:770-877-3005
Mailing Address - Fax:770-877-3007
Practice Address - Street 1:11 LEGACY WAY
Practice Address - Street 2:STE E
Practice Address - City:ADAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30103-2464
Practice Address - Country:US
Practice Address - Phone:770-877-3005
Practice Address - Fax:770-877-3007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0094643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1157254OtherNCPDP PROVIDER IDENTIFICATION NUMBER
GA155898320AMedicaid