Provider Demographics
NPI:1801170634
Name:BRADBURY, KIETH DANA (PHARMACIST)
Entity type:Individual
Prefix:
First Name:KIETH
Middle Name:DANA
Last Name:BRADBURY
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 JEWETT RD
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-1905
Mailing Address - Country:US
Mailing Address - Phone:978-922-3212
Mailing Address - Fax:978-750-4334
Practice Address - Street 1:11 NEWBURY ST
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-1014
Practice Address - Country:US
Practice Address - Phone:978-750-4334
Practice Address - Fax:978-750-4897
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19287183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist