Provider Demographics
NPI:1568948693
Name:DUNSWORTH, BREANNE LEE (PHARMD)
Entity Type:Individual
Prefix:
First Name:BREANNE
Middle Name:LEE
Last Name:DUNSWORTH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 ROSEWOOD TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-8464
Mailing Address - Country:US
Mailing Address - Phone:314-221-8193
Mailing Address - Fax:
Practice Address - Street 1:150 WATERLOO COMMONS DR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1060
Practice Address - Country:US
Practice Address - Phone:618-939-3942
Practice Address - Fax:618-939-3943
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016000201183500000X
IL051.299363183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist