Provider Demographics
NPI:1093181182
Name:OVER, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:OVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 AMHERST CIR # IR
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-5200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 SPALDING DR STE 101
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6551
Practice Address - Country:US
Practice Address - Phone:630-527-5204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051040331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL249156OtherNCPDP