Provider Demographics
NPI:1285787408
Name:BRADDY, BEN
Entity type:Individual
Prefix:MR
First Name:BEN
Middle Name:
Last Name:BRADDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W ANDREWS ST
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061
Mailing Address - Country:US
Mailing Address - Phone:478-454-1026
Mailing Address - Fax:
Practice Address - Street 1:200 W ANDREWS ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-3839
Practice Address - Country:US
Practice Address - Phone:478-454-1026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA15300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist