Provider Demographics
NPI:1194713792
Name:BRADLEY, JEANINE M (RPH)
Entity type:Individual
Prefix:MS
First Name:JEANINE
Middle Name:M
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 1:345 MONTERRA DR
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-9574
Mailing Address - Country:US
Mailing Address - Phone:360-681-6179
Mailing Address - Fax:360-681-6179
Practice Address - Street 1:345 MONTERRA DR
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-9574
Practice Address - Country:US
Practice Address - Phone:360-681-6179
Practice Address - Fax:360-681-6179
Is Sole Proprietor?:No
Enumeration Date:2005-10-09
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA09730183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist