MEDICARE: MR. BRIAN THOMAS MCDONOUGH RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	26017473A	IN

General Provider Information

NPI Number	:	1326238700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN THOMAS MCDONOUGH RPH

Provider Business Mailing Address
First Line	:	12705 MORNING DOVE DR
Second Line	:
City	:	CEDAR LAKE
State	:	IN
Zip	:	46303-8607
Country	:	US
Telephone Number	:	219-374-8824
Fax Number	:	219-374-8824

Provider Business Practice Location Address
First Line	:	805 S LAKE ST
Second Line	:
City	:	GARY
State	:	IN
Zip	:	46403-2918
Country	:	US
Telephone Number	:	219-938-4857
Fax Number	:	219-938-4809

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2007
Last Update Date	:	07/31/2007

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