Provider Demographics
NPI:1659823748
Name:BRADFORD, KHRISTY (PD)
Entity type:Individual
Prefix:
First Name:KHRISTY
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 ELIZABETH RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:LA
Mailing Address - Zip Code:71454-5648
Mailing Address - Country:US
Mailing Address - Phone:318-646-2370
Mailing Address - Fax:318-899-5069
Practice Address - Street 1:19479 HIGHWAY 167
Practice Address - Street 2:
Practice Address - City:BENTLEY
Practice Address - State:LA
Practice Address - Zip Code:71407-3502
Practice Address - Country:US
Practice Address - Phone:318-899-5066
Practice Address - Fax:318-899-5069
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.014708183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist