Healthcare Provider Details

I. General information

NPI: 1780289538
Provider Name (Legal Business Name): LAURA SWATZYNA BRADFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 11/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CVS PHARMACY 3909 CHALLENGER AVENUE
ROANOKE VA
24012
US

IV. Provider business mailing address

CVS PHARMACY 3909 CHALLENGER AVENUE
ROANOKE VA
24012
US

V. Phone/Fax

Practice location:
  • Phone: 540-977-1376
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202212264
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number0202212264
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number0202212264
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: