Provider Demographics
NPI:1134302839
Name:RICKEY, THOMAS (RPH)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:RICKEY
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 1:10424 N OSAGE CT
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525
Mailing Address - Country:US
Mailing Address - Phone:309-243-8767
Mailing Address - Fax:
Practice Address - Street 1:10424 N OSAGE CT
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:IL
Practice Address - Zip Code:61525
Practice Address - Country:US
Practice Address - Phone:309-243-8767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist