Provider Demographics
NPI:1063511566
Name:THOMPSON, BRUCE L (RPH)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:L
Last Name:THOMPSON
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 1:5209 GARRICK AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-2138
Mailing Address - Country:US
Mailing Address - Phone:817-294-1750
Mailing Address - Fax:817-294-4565
Practice Address - Street 1:6708 LAKE WORTH BLVD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-2902
Practice Address - Country:US
Practice Address - Phone:817-237-7580
Practice Address - Fax:817-237-7581
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20832183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist