Provider Demographics
NPI:1912225343
Name:BRADDOCK, CHAD JEREMY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:JEREMY
Last Name:BRADDOCK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 DESOTO AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-5214
Mailing Address - Country:US
Mailing Address - Phone:662-627-0100
Mailing Address - Fax:662-627-0102
Practice Address - Street 1:425 DESOTO AVE
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-5214
Practice Address - Country:US
Practice Address - Phone:662-627-0100
Practice Address - Fax:662-627-0102
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-10
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33492183500000X
MSE-09330183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist