Healthcare Provider Details

I. General information

NPI: 1902157712
Provider Name (Legal Business Name): BRADLEY FREE CLINIC OF ROANOKE VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2012
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 3RD ST SW
ROANOKE VA
24016-4612
US

IV. Provider business mailing address

1240 3RD ST SW
ROANOKE VA
24016-4612
US

V. Phone/Fax

Practice location:
  • Phone: 540-344-5156
  • Fax: 540-777-0726
Mailing address:
  • Phone: 540-344-5156
  • Fax: 540-777-0726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0201002648
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JAMES BLACK
Title or Position: PHARMACIST IN CHARGE
Credential:
Phone: 540-344-5156