Healthcare Provider Details

I. General information

NPI: 1174248595
Provider Name (Legal Business Name): MICHAEL KEITH BRADY PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2022
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 STATE ROAD 312 W
SAINT AUGUSTINE FL
32086-4201
US

IV. Provider business mailing address

175 STATE ROAD 312 W
SAINT AUGUSTINE FL
32086-4201
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-6167
  • Fax:
Mailing address:
  • Phone: 904-824-6167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS49315
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: