Basic Information
Provider Information
NPI: 1497801823
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BROZENEC
FirstName: PETER
MiddleName: JOHN
NamePrefix: MR.
NameSuffix:  
Credential: R.PH.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1302 HERITAGE RD E
Address2:  
City: NORMAL
State: IL
PostalCode: 617611302
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1505 EASTLAND DR
Address2:  
City: BLOOMINGTON
State: IL
PostalCode: 617013534
CountryCode: US
TelephoneNumber: 3096640505
FaxNumber:  
Other Information
ProviderEnumerationDate: 01/26/2007
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X ILY Pharmacy Service ProvidersPharmacist 

No ID Information.


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