Basic Information
| Provider Information | |||||||||
| NPI: | 1134720303 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | MARIANA | ||||||||
| MiddleName: | LIZZETTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3707 BUFFALO RD | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250339436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049374204 | ||||||||
| FaxNumber: | 3049374206 | ||||||||
| Practice Location | |||||||||
| Address1: | 3707 BUFFALO RD | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250339436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049374204 | ||||||||
| FaxNumber: | 3049374206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2020 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | RP0007655 | WV | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.