Provider Demographics
NPI:1528685864
Name:TABAAC, BRADLEY EVAN (RPH)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:EVAN
Last Name:TABAAC
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 LEON CIR
Mailing Address - Street 2:
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-1955
Mailing Address - Country:US
Mailing Address - Phone:215-869-4242
Mailing Address - Fax:215-425-5594
Practice Address - Street 1:2258 N FRONT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-3714
Practice Address - Country:US
Practice Address - Phone:215-425-5230
Practice Address - Fax:215-425-5594
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP032545L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist