Healthcare Provider Details

I. General information

NPI: 1558181784
Provider Name (Legal Business Name): BRADLEY TYLER PETERSON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BRAD PETERSON PHARMD

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 07/26/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8315 MAGNOLIA ESTATES DR
CORNELIUS NC
28031-7837
US

IV. Provider business mailing address

13334 OLD STORE RD
HUNTERSVILLE NC
28078-7435
US

V. Phone/Fax

Practice location:
  • Phone: 704-895-7062
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberI-49482
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number34821
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number02537
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: