Healthcare Provider Details

I. General information

NPI: 1871246546
Provider Name (Legal Business Name): GEORGE SULLIVAN BRADBURY III PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 COOPERTOWNE BLVD
SOMERDALE NJ
08083-1433
US

IV. Provider business mailing address

2114 E DAUPHIN ST
PHILADELPHIA PA
19125-2006
US

V. Phone/Fax

Practice location:
  • Phone: 856-545-9074
  • Fax:
Mailing address:
  • Phone: 856-275-5417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI03742500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: