Provider Demographics
NPI:1013311299
Name:PETROVICH, TAMARA (PHARMD)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:PETROVICH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-8827
Mailing Address - Country:US
Mailing Address - Phone:773-315-8883
Mailing Address - Fax:
Practice Address - Street 1:841 BLOOMINGTON RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-2101
Practice Address - Country:US
Practice Address - Phone:217-356-4827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-16
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.289205183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist