Healthcare Provider Details

I. General information

NPI: 1659275022
Provider Name (Legal Business Name): BRADLEY PETERSON
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1549 GALE LEMERAND DR
GAINESVILLE FL
32610-3008
US

IV. Provider business mailing address

7200 SW 8TH AVE APT 136
GAINESVILLE FL
32607-5814
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-8272
  • Fax: 352-627-4645
Mailing address:
  • Phone: 352-265-8272
  • Fax: 352-627-4645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: