Provider Demographics
NPI:1750664892
Name:SURBER, TAIT MATTHEW (PHARMD)
Entity Type:Individual
Prefix:
First Name:TAIT
Middle Name:MATTHEW
Last Name:SURBER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 US 31W BYP
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-2419
Mailing Address - Country:US
Mailing Address - Phone:270-842-3339
Mailing Address - Fax:270-842-4139
Practice Address - Street 1:1145 US 31W BYP
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2419
Practice Address - Country:US
Practice Address - Phone:270-842-3339
Practice Address - Fax:270-842-4139
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY013526183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist