Provider Demographics
NPI:1861979569
Name:BRADLEY, KATRINA ELIZABETH (PHARMD)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:ELIZABETH
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2171 BUCK CV
Mailing Address - Street 2:
Mailing Address - City:PEA RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72751-5000
Mailing Address - Country:US
Mailing Address - Phone:479-426-0614
Mailing Address - Fax:
Practice Address - Street 1:2833 BELLA VISTA WAY
Practice Address - Street 2:
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72714-3709
Practice Address - Country:US
Practice Address - Phone:479-876-2153
Practice Address - Fax:479-876-2184
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD14611183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPD14611OtherPHARMACIST LICENSE