Provider Demographics
NPI:1841580255
Name:BROCK, TANYA M (PHARM D)
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:M
Last Name:BROCK
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 RICHMOND ST
Mailing Address - Street 2:P.O BOX 1003
Mailing Address - City:MOUNT VERNON
Mailing Address - State:KY
Mailing Address - Zip Code:40456-2307
Mailing Address - Country:US
Mailing Address - Phone:606-256-9207
Mailing Address - Fax:
Practice Address - Street 1:1040 RICHMOND ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:KY
Practice Address - Zip Code:40456-2307
Practice Address - Country:US
Practice Address - Phone:606-256-9207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY012456183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist