Provider Demographics
NPI:1982386322
Name:BRANNAN, TEAL
Entity Type:Individual
Prefix:
First Name:TEAL
Middle Name:
Last Name:BRANNAN
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 1:1795 E STATE ROAD 163
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47842-7327
Mailing Address - Country:US
Mailing Address - Phone:765-832-3539
Mailing Address - Fax:765-832-3542
Practice Address - Street 1:1795 E STATE ROAD 163
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IN
Practice Address - Zip Code:47842-7327
Practice Address - Country:US
Practice Address - Phone:765-832-3539
Practice Address - Fax:765-832-3542
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-04
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26030383A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist