Provider Demographics
NPI:1801836192
Name:BRATLAND, LEO V (R PH)
Entity Type:Individual
Prefix:MR
First Name:LEO
Middle Name:V
Last Name:BRATLAND
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-1216
Mailing Address - Country:US
Mailing Address - Phone:217-442-2472
Mailing Address - Fax:217-442-2477
Practice Address - Street 1:8 E NORTH ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5804
Practice Address - Country:US
Practice Address - Phone:217-442-2472
Practice Address - Fax:217-442-2477
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1459999OtherNABP
IL271275906001Medicaid
IL271275906001Medicaid