Provider Demographics
NPI:1619552676
Name:DUNHAM, TARA CORINNE (PHARMACY TECHNICIAN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:CORINNE
Last Name:DUNHAM
Suffix:
Gender:F
Credentials:PHARMACY TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15230 RED TAIL DR APT D8
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:MI
Mailing Address - Zip Code:48808-9814
Mailing Address - Country:US
Mailing Address - Phone:517-763-5362
Mailing Address - Fax:517-487-9163
Practice Address - Street 1:3225 TOWNE CENTRE BLVD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-5620
Practice Address - Country:US
Practice Address - Phone:517-487-9161
Practice Address - Fax:517-487-9163
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303004825183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician