Provider Demographics
NPI:1528119856
Name:DEEGAN, BRADLEY S (PHARMD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:S
Last Name:DEEGAN
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 1:3392 WOODLYN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:ERLANGER
Mailing Address - State:KY
Mailing Address - Zip Code:41018-2600
Mailing Address - Country:US
Mailing Address - Phone:859-426-7764
Mailing Address - Fax:513-475-5269
Practice Address - Street 1:311 STRAIGHT ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-1018
Practice Address - Country:US
Practice Address - Phone:513-559-2346
Practice Address - Fax:513-475-5269
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-1-24778183500000X
KY012193183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY012193OtherKY PHARMACIST LICENSE #
OH03-1-24778OtherOHIO PHARMACIST LICENSE #