Provider Demographics
NPI:1912329806
Name:TUCKER, BRADY (PHARM D)
Entity type:Individual
Prefix:
First Name:BRADY
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 WASHINGTON ST S
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1403 NORTH MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634
Practice Address - Country:US
Practice Address - Phone:208-922-9566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6825183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist