Healthcare Provider Details

I. General information

NPI: 1144806159
Provider Name (Legal Business Name): BRADLEY JOE HAYMON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2021
Last Update Date: 03/20/2021
Certification Date: 03/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 WEST MAIN STREET
RAINSVILLE AL
35986
US

IV. Provider business mailing address

PO BOX 428
RAINSVILLE AL
35986-0428
US

V. Phone/Fax

Practice location:
  • Phone: 256-638-4142
  • Fax: 256-638-4149
Mailing address:
  • Phone: 256-638-4142
  • Fax: 256-638-4149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13935
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: