Provider Demographics
NPI:1730208372
Name:EIDE, BRADLEY JOHN (RPH)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:JOHN
Last Name:EIDE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 E LARKSPUR LN
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-8304
Mailing Address - Country:US
Mailing Address - Phone:608-779-5550
Mailing Address - Fax:
Practice Address - Street 1:1475 W SERVICE DR
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-2512
Practice Address - Country:US
Practice Address - Phone:507-452-5254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116710183500000X
VA0202009270183500000X
WI13071-040183500000X
ND4002183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist