Provider Demographics
NPI:1164024048
Name:THOMAS, ANDREA MARIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 833
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-0833
Mailing Address - Country:US
Mailing Address - Phone:580-236-4965
Mailing Address - Fax:
Practice Address - Street 1:1907 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-5253
Practice Address - Country:US
Practice Address - Phone:580-286-3323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-15
Last Update Date:2020-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19021183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist