Provider Demographics
NPI:1811287147
Name:BRADLEY, JACK LEWIS II (RPH)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:LEWIS
Last Name:BRADLEY
Suffix:II
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 1:3275 NATURES TRAIL CT
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-9744
Mailing Address - Country:US
Mailing Address - Phone:803-327-2185
Mailing Address - Fax:803-684-6315
Practice Address - Street 1:630 E LIBERTY ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:SC
Practice Address - Zip Code:29745-1605
Practice Address - Country:US
Practice Address - Phone:803-684-6934
Practice Address - Fax:803-684-6315
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6154183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist