Provider Demographics
NPI:1063023919
Name:THOMAS, CALEB
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:
Last Name:THOMAS
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 1:13219 E 31ST PL APT 1311
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74134-3464
Mailing Address - Country:US
Mailing Address - Phone:214-493-9625
Mailing Address - Fax:
Practice Address - Street 1:3751 N ASPEN AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-1109
Practice Address - Country:US
Practice Address - Phone:918-355-2317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18536183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist