Provider Demographics
NPI:1871139030
Name:TATRO, BRIAN KEITH (RPH)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KEITH
Last Name:TATRO
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 1:3070 N WATER ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-1991
Mailing Address - Country:US
Mailing Address - Phone:217-877-1327
Mailing Address - Fax:
Practice Address - Street 1:3070 N WATER ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-1991
Practice Address - Country:US
Practice Address - Phone:217-877-1327
Practice Address - Fax:309-877-1328
Is Sole Proprietor?:No
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-037717183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist