Provider Demographics
NPI:1194133660
Name:BRADLEY, LORI RAE (RPH)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:RAE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6021 W RED BERRY HILL LN
Mailing Address - Street 2:
Mailing Address - City:KELSEY
Mailing Address - State:CA
Mailing Address - Zip Code:95667-7402
Mailing Address - Country:US
Mailing Address - Phone:530-622-0206
Mailing Address - Fax:
Practice Address - Street 1:6021 W RED BERRY HILL LN
Practice Address - Street 2:
Practice Address - City:KELSEY
Practice Address - State:CA
Practice Address - Zip Code:95667-7402
Practice Address - Country:US
Practice Address - Phone:530-622-0206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49569183500000X
IN26019332A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA152282OtherNABP