Provider Demographics
NPI:1831339464
Name:PHILLIPS, BRADLEY (PHARM D)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 W 54TH ST
Mailing Address - Street 2:APT 25B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-5539
Mailing Address - Country:US
Mailing Address - Phone:212-608-8416
Mailing Address - Fax:212-608-8457
Practice Address - Street 1:260 W 54TH ST
Practice Address - Street 2:APT 25B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-5539
Practice Address - Country:US
Practice Address - Phone:212-608-8416
Practice Address - Fax:212-608-8457
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-22
Last Update Date:2009-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053072183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY002461154Medicaid