Provider Demographics
NPI:1174248595
Name:BRADY, MICHAEL KEITH (PHARMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEITH
Last Name:BRADY
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 1:175 STATE ROAD 312 W
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4201
Mailing Address - Country:US
Mailing Address - Phone:904-824-6167
Mailing Address - Fax:
Practice Address - Street 1:175 STATE ROAD 312 W
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4201
Practice Address - Country:US
Practice Address - Phone:904-824-6167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS49315183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist