Provider Demographics
NPI:1891390001
Name:ITAMURA, TAD GORDON (RPH)
Entity Type:Individual
Prefix:
First Name:TAD
Middle Name:GORDON
Last Name:ITAMURA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11026 TENACIOUS DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-9566
Mailing Address - Country:US
Mailing Address - Phone:317-985-2077
Mailing Address - Fax:
Practice Address - Street 1:505 E THOMPSON RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-1626
Practice Address - Country:US
Practice Address - Phone:317-784-9716
Practice Address - Fax:317-780-7478
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016350A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty