MEDICARE: MR. BRADLEY SCOT DENOVCHEK RPH

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	RPH020179	GA

General Provider Information

NPI Number	:	1295021780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRADLEY SCOT DENOVCHEK RPH

Provider Business Mailing Address
First Line	:	2625 PEACHTREE PKWY
Second Line	:	T-2056
City	:	SUWANEE
State	:	GA
Zip	:	30024-1048
Country	:	US
Telephone Number	:	678-965-5806
Fax Number	:

Provider Business Practice Location Address
First Line	:	2625 PEACHTREE PKWY
Second Line	:	T-2056
City	:	SUWANEE
State	:	GA
Zip	:	30024-1048
Country	:	US
Telephone Number	:	678-965-5806
Fax Number	:

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

Provider Enumeration Date	:	06/22/2011
Last Update Date	:	06/22/2011

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