Healthcare Provider Details

I. General information

NPI: 1568070563
Provider Name (Legal Business Name): BRADLEY KEITH ROWLAND RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 S JEFFERSON
MARSHALL MO
65340-0917
US

IV. Provider business mailing address

157 S JEFFERSON
MARSHALL MO
65340-0917
US

V. Phone/Fax

Practice location:
  • Phone: 660-886-5515
  • Fax: 660-886-2890
Mailing address:
  • Phone: 660-886-5515
  • Fax: 660-886-2890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number041988
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number041988
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: