Provider Demographics
NPI:1356005854
Name:THOMAS-FENNELLY, ADAM WYATT (PHARMD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:WYATT
Last Name:THOMAS-FENNELLY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 NEWSOM AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-5172
Mailing Address - Country:US
Mailing Address - Phone:812-341-9640
Mailing Address - Fax:
Practice Address - Street 1:700 US HIGHWAY 31 S
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-2401
Practice Address - Country:US
Practice Address - Phone:317-883-0567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26029542A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist