Provider Demographics
NPI:1629224712
Name:TANNER, SARA (PHARMD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:NEELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:750 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-1027
Mailing Address - Country:US
Mailing Address - Phone:765-472-8900
Mailing Address - Fax:765-472-8999
Practice Address - Street 1:750 N BROADWAY
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1027
Practice Address - Country:US
Practice Address - Phone:765-472-8900
Practice Address - Fax:765-472-8999
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-08
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS44013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist