Provider Demographics
NPI:1811306905
Name:CAMMACK, BRAD
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:CAMMACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1648 E IDAHO AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-3008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1648 E IDAHO AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-3008
Practice Address - Country:US
Practice Address - Phone:541-889-6315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0011434183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist