Provider Demographics
NPI:1487754099
Name:BRADEN, LARRY L (RPH)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:L
Last Name:BRADEN
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 1:4797 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-5339
Mailing Address - Country:US
Mailing Address - Phone:770-974-5234
Mailing Address - Fax:770-974-3028
Practice Address - Street 1:4797 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-5339
Practice Address - Country:US
Practice Address - Phone:770-974-5234
Practice Address - Fax:770-974-3028
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008980183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA30019170AMedicaid
GA00030357BMedicaid
GA87BBBBMMedicare ID - Type UnspecifiedPART B
GA00030357BMedicaid