Provider Demographics
NPI:1386912889
Name:MIGUT, TAMARA
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:MIGUT
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 1:202 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:TOLONO
Mailing Address - State:IL
Mailing Address - Zip Code:61880-9461
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 E UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802-2500
Practice Address - Country:US
Practice Address - Phone:217-344-7201
Practice Address - Fax:217-344-7290
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051287256183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist