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General NPI Number Information
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NPI Number | 1154807147
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Entity Type | Individual
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Provider Name | BRENDA MARIE TANKER
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Gender | Female
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Dates
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Enumeration Date | 07/13/2018
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Last Update Date | 07/13/2018
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Provider Practice Location Address
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Address Line | 2642 CHARLES ST
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City | ROCKFORD
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State | IL
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Zip | 61108-1671
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Country | US
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Telephone | 815-484-2461
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Fax |
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Provider Business Mailing Address
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Address Line | 11156 BAYBERRY DR
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City | ROSCOE
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State | IL
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Zip | 61073-8127
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1835P0018X
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Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
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License Number | 051.290847
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License Number State | IL
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