Provider Demographics
NPI:1629608773
Name:TAITT, MADELINE LEA
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:LEA
Last Name:TAITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 E INDUSTRIAL PARK RD UNIT 1
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966-3947
Mailing Address - Country:US
Mailing Address - Phone:618-687-9454
Mailing Address - Fax:
Practice Address - Street 1:3637 HERRIN RD
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-3156
Practice Address - Country:US
Practice Address - Phone:618-687-9454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0510376971835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist