Healthcare Provider Details

I. General information

NPI: 1003219726
Provider Name (Legal Business Name): CARSON BRADY PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2014
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 WINDSOR HIGHWAY
VAILS GATE NY
12553
US

IV. Provider business mailing address

16 JOHN ST
SOUTH GLENS FALLS NY
12803-5214
US

V. Phone/Fax

Practice location:
  • Phone: 845-863-1054
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number059279
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: