Healthcare Provider Details

I. General information

NPI: 1598990020
Provider Name (Legal Business Name): BRADD M WAKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 05/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR BLDG 7500
COLORADO SPRINGS CO
80913-4613
US

IV. Provider business mailing address

1650 COCHRANE CIR BLDG 7500
COLORADO SPRINGS CO
80913-4613
US

V. Phone/Fax

Practice location:
  • Phone: 719-524-4400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number60742
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: