Provider Demographics
NPI:1699363762
Name:SMITH, BRIAN DAVID (PHARMD BCPS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:DAVID
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHARMD BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 DR WARREN TUTTLE DR
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-2718
Mailing Address - Country:US
Mailing Address - Phone:618-253-0243
Mailing Address - Fax:
Practice Address - Street 1:100 DR WARREN TUTTLE DR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-2718
Practice Address - Country:US
Practice Address - Phone:618-253-0243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.293412183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist