Healthcare Provider Details

I. General information

NPI: 1255845046
Provider Name (Legal Business Name): LAETITIA BRADFORD PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2017
Last Update Date: 12/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 PEACHTREE RD NE
ATLANTA GA
30326-1039
US

IV. Provider business mailing address

523 VININGS OAKS RUN
MABLETON GA
30126-7240
US

V. Phone/Fax

Practice location:
  • Phone: 866-787-6341
  • Fax:
Mailing address:
  • Phone: 786-325-8353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH026168
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: