Provider Demographics
NPI:1912503780
Name:REAM, TANYA DENISE
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:DENISE
Last Name:REAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E LAGRANGE RD
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:IN
Mailing Address - Zip Code:47243-9447
Mailing Address - Country:US
Mailing Address - Phone:812-866-5599
Mailing Address - Fax:812-866-2018
Practice Address - Street 1:110 E LAGRANGE RD
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:IN
Practice Address - Zip Code:47243-9447
Practice Address - Country:US
Practice Address - Phone:812-866-5599
Practice Address - Fax:812-866-2018
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019616A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist