Healthcare Provider Details

I. General information

NPI: 1396911996
Provider Name (Legal Business Name): CAMISHA TANNER PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2008
Last Update Date: 11/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1254 N HARDING AVE
CHICAGO IL
60651-2023
US

IV. Provider business mailing address

1254 N HARDING AVE
CHICAGO IL
60651-2023
US

V. Phone/Fax

Practice location:
  • Phone: 773-299-2910
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number049.162066
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.292995
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: