Provider Demographics
NPI:1407109077
Name:BRUNER, TERRY J (RPH)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:J
Last Name:BRUNER
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 1:222 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-1828
Mailing Address - Country:US
Mailing Address - Phone:847-526-2591
Mailing Address - Fax:847-526-1598
Practice Address - Street 1:222 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084-1828
Practice Address - Country:US
Practice Address - Phone:847-526-2591
Practice Address - Fax:847-526-1598
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051035826183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist