Provider Demographics
NPI:1912940313
Name:BRADBERRY, JACK C (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:C
Last Name:BRADBERRY
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 1:13235 HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-5293
Mailing Address - Country:US
Mailing Address - Phone:402-758-6666
Mailing Address - Fax:
Practice Address - Street 1:2500 CALIFORNIA PLZ
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68178-0001
Practice Address - Country:US
Practice Address - Phone:402-280-2950
Practice Address - Fax:402-280-5738
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA92241835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy