Provider Demographics
NPI:1699467290
Name:HAMILTON, BRADLEY TAYLOR
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:TAYLOR
Last Name:HAMILTON
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 1:4308 CLUBHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-8081
Mailing Address - Country:US
Mailing Address - Phone:870-351-2697
Mailing Address - Fax:870-956-0302
Practice Address - Street 1:4308 CLUBHOUSE DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72405-8081
Practice Address - Country:US
Practice Address - Phone:870-351-2697
Practice Address - Fax:870-956-0302
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD11431183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist