Provider Demographics
NPI:1194030114
Name:BRANDON, TARA LOUISE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LOUISE
Last Name:BRANDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2846 MACKEY RANCH RD
Mailing Address - Street 2:
Mailing Address - City:MOODY
Mailing Address - State:TX
Mailing Address - Zip Code:76557-4115
Mailing Address - Country:US
Mailing Address - Phone:254-717-9418
Mailing Address - Fax:
Practice Address - Street 1:3801 N 19TH ST
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-1675
Practice Address - Country:US
Practice Address - Phone:254-753-6277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX48603183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist