MEDICARE: MR. BRAD SCOTT PRUITT R.PH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PH00015382	WA

General Provider Information

NPI Number	:	1255797171
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRAD SCOTT PRUITT R.PH

Provider Business Mailing Address
First Line	:	4305 LAKE WASHINGTON BLVD NE
Second Line	:	2108
City	:	KIRKLAND
State	:	WA
Zip	:	98033-7883
Country	:	US
Telephone Number	:	415-571-4724
Fax Number	:

Provider Business Practice Location Address
First Line	:	4305 LAKE WASHINGTON BLVD NE
Second Line	:	2108
City	:	KIRKLAND
State	:	WA
Zip	:	98033-7883
Country	:	US
Telephone Number	:	415-571-4724
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2016
Last Update Date	:	01/07/2016

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