Provider Demographics
NPI:1427659820
Name:HERRON, BRENT D
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:D
Last Name:HERRON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 N PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1251
Mailing Address - Country:US
Mailing Address - Phone:217-352-1490
Mailing Address - Fax:
Practice Address - Street 1:2610 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1251
Practice Address - Country:US
Practice Address - Phone:217-352-1490
Practice Address - Fax:317-352-1490
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26023781A183500000X
IL051302607183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
162420OtherNABP