Provider Demographics
NPI:1093302952
Name:MICKNICK, THOMAS JOSEPH (RPH)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOSEPH
Last Name:MICKNICK
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 1:217 BELL MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:JERMYN
Mailing Address - State:PA
Mailing Address - Zip Code:18433-3611
Mailing Address - Country:US
Mailing Address - Phone:570-878-2843
Mailing Address - Fax:
Practice Address - Street 1:658 ROUTE 739 STE 5
Practice Address - Street 2:
Practice Address - City:HAWLEY
Practice Address - State:PA
Practice Address - Zip Code:18428-6086
Practice Address - Country:US
Practice Address - Phone:570-775-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-27
Last Update Date:2020-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP036724L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist