Provider Demographics
NPI:1073934089
Name:HARGROVE, THOMAS
Entity Type:Individual
Prefix:MISS
First Name:THOMAS
Middle Name:
Last Name:HARGROVE
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 1:813 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-2824
Mailing Address - Country:US
Mailing Address - Phone:662-455-3532
Mailing Address - Fax:662-455-2142
Practice Address - Street 1:813 WEST PARK AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930
Practice Address - Country:US
Practice Address - Phone:662-455-3532
Practice Address - Fax:662-455-2142
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-17
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE6524183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist