=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730434572
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROGER BARRY BRADLEY RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2012
-----------------------------------------------------
Last Update Date | 12/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1537 CHARLESTON HWY
-----------------------------------------------------
City | WEST COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29169-5047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-796-3392
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6510 DARE CIR
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29206-1153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-240-8891
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 13701
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------