Healthcare Provider Details

I. General information

NPI: 1114715760
Provider Name (Legal Business Name): BRADY ANDREW KOVALSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2025
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WHEELING AVE
GLEN DALE WV
26038-1697
US

IV. Provider business mailing address

800 WHEELING AVE
GLEN DALE WV
26038-1697
US

V. Phone/Fax

Practice location:
  • Phone: 304-845-3211
  • Fax:
Mailing address:
  • Phone: 304-845-3211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP0010780
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: