Provider Demographics
NPI:1104007392
Name:THOMPSON, MARK J
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:THOMPSON
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 1:451 JUNCTION RD
Mailing Address - Street 2:COMPLIANCE MAIL CODE 9901
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-2656
Mailing Address - Country:US
Mailing Address - Phone:608-265-7070
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:COMPLIANCE MAIL CODE 2433
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0001
Practice Address - Country:US
Practice Address - Phone:608-662-0817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11808183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11808OtherPHARMACIST