Healthcare Provider Details

I. General information

NPI: 1437061579
Provider Name (Legal Business Name): BRADLEY MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BRAD MOORE

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4417 VESTAL PKWY E
VESTAL NY
13850-3556
US

IV. Provider business mailing address

145 QUINN RD
FRIENDSVILLE PA
18818-8743
US

V. Phone/Fax

Practice location:
  • Phone: 607-770-7365
  • Fax:
Mailing address:
  • Phone: 607-763-6135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number063566
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: