Healthcare Provider Details

I. General information

NPI: 1467627455
Provider Name (Legal Business Name): BRADLEY KENT DAGEN JR. PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 E MICHIGAN AVE
PAW PAW MI
49079-1426
US

IV. Provider business mailing address

230 N KALAMAZOO MALL UNIT 202
KALAMAZOO MI
49007-5829
US

V. Phone/Fax

Practice location:
  • Phone: 269-657-4440
  • Fax:
Mailing address:
  • Phone: 231-215-1277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302035361
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: