Provider Demographics
NPI:1417237017
Name:TAM, DANIEL Y (RPH)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:Y
Last Name:TAM
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 1:8502 BUCKI LN
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60480-1172
Mailing Address - Country:US
Mailing Address - Phone:708-408-9833
Mailing Address - Fax:708-386-9421
Practice Address - Street 1:8502 BUCKI LN
Practice Address - Street 2:
Practice Address - City:WILLOW SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60480-1172
Practice Address - Country:US
Practice Address - Phone:708-408-9833
Practice Address - Fax:708-386-9421
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-032122183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051032122OtherILLINOIS RPH LICENSE