Provider Demographics
NPI:1093838435
Name:THOMAS, JACK R
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:R
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 1:160-23RD. ST. NW
Mailing Address - Street 2:
Mailing Address - City:EAST WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98802
Mailing Address - Country:US
Mailing Address - Phone:253-225-4711
Mailing Address - Fax:509-267-6667
Practice Address - Street 1:100 JOHNSON
Practice Address - Street 2:
Practice Address - City:CHELAN
Practice Address - State:WA
Practice Address - Zip Code:98816
Practice Address - Country:US
Practice Address - Phone:509-682-4087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA9790183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist