Provider Demographics
NPI:1053693606
Name:ALSUP, BRADLEY WADE (PHARMD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:WADE
Last Name:ALSUP
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 NEW SHACKLE ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-2328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:365 NEW SHACKLE ISLAND RD
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2328
Practice Address - Country:US
Practice Address - Phone:615-826-1323
Practice Address - Fax:615-826-6694
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33405183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist