=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891446787
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADY BERNARD RATLIFF PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2022
-----------------------------------------------------
Last Update Date | 06/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31 E VALLEY DR
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24201-2822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-669-4640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38 MEADOWS EDGE CT
-----------------------------------------------------
City | JONESBOROUGH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37659-4482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-494-3005
-----------------------------------------------------
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 | 020220426
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 45141
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------