Provider Demographics
NPI:1750665733
Name:ALLEN, BRENDA S (BS)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:S
Last Name:ALLEN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 NORTH ELM
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801
Mailing Address - Country:US
Mailing Address - Phone:618-533-5395
Mailing Address - Fax:618-533-5506
Practice Address - Street 1:225 N ELM ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3248
Practice Address - Country:US
Practice Address - Phone:618-533-5395
Practice Address - Fax:618-533-5506
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.287999183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist