Provider Demographics
NPI:1093111429
Name:KALISTA, THOMAS (PHARMD, CDOE, CVDOE)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:KALISTA
Suffix:
Gender:M
Credentials:PHARMD, CDOE, CVDOE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 WILLETT AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-2067
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1086 WILLETT AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-2067
Practice Address - Country:US
Practice Address - Phone:401-433-5710
Practice Address - Fax:401-433-5713
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI5246183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist