Provider Demographics
NPI:1275131070
Name:THOMAS, MAIVEL SAMIR
Entity Type:Individual
Prefix:
First Name:MAIVEL
Middle Name:SAMIR
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12050 HIGHWAY 92 STE 112
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-4287
Mailing Address - Country:US
Mailing Address - Phone:770-591-2895
Mailing Address - Fax:770-591-8463
Practice Address - Street 1:12050 HIGHWAY 92 STE 112
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4287
Practice Address - Country:US
Practice Address - Phone:770-591-2895
Practice Address - Fax:770-591-8463
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0264571835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist