Provider Demographics
NPI:1326590183
Name:THISTLETHWAITE, TARA D
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:D
Last Name:THISTLETHWAITE
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:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70589-0446
Mailing Address - Country:US
Mailing Address - Phone:337-826-3677
Mailing Address - Fax:337-826-5070
Practice Address - Street 1:310 N MAIN ST.
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:LA
Practice Address - Zip Code:70589-0446
Practice Address - Country:US
Practice Address - Phone:337-826-3677
Practice Address - Fax:337-826-5070
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15063183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist