Healthcare Provider Details

I. General information

NPI: 1407765431
Provider Name (Legal Business Name): DEANDRA BRADLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3515 VICTORY DR
COLUMBUS GA
31903-2733
US

IV. Provider business mailing address

3515 VICTORY DR
COLUMBUS GA
31903-2733
US

V. Phone/Fax

Practice location:
  • Phone: 706-568-4571
  • Fax: 706-568-4933
Mailing address:
  • Phone: 706-568-4571
  • Fax: 706-568-4933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH036490
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: