Provider Demographics
NPI:1811263841
Name:BRADFORD, JOHN MARK (RPH)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
Last Name:BRADFORD
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 1:7420 GUTHRIE DR N STE 110
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5877
Mailing Address - Country:US
Mailing Address - Phone:662-536-0384
Mailing Address - Fax:877-536-4207
Practice Address - Street 1:7420 GUTHRIE DR N STE 110
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5877
Practice Address - Country:US
Practice Address - Phone:662-536-0384
Practice Address - Fax:877-536-4207
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-23
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-010483183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist