Provider Demographics
NPI:1326238700
Name:MCDONOUGH, BRIAN THOMAS (RPH)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:THOMAS
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12705 MORNING DOVE DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-8607
Mailing Address - Country:US
Mailing Address - Phone:219-374-8824
Mailing Address - Fax:219-374-8824
Practice Address - Street 1:805 S LAKE ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46403-2918
Practice Address - Country:US
Practice Address - Phone:219-938-4857
Practice Address - Fax:219-938-4809
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26017473A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist