Provider Demographics
NPI:1376090076
Name:THACKER, CHANNING
Entity Type:Individual
Prefix:
First Name:CHANNING
Middle Name:
Last Name:THACKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 HENCH CIR APT 5
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-6919
Mailing Address - Country:US
Mailing Address - Phone:606-253-1260
Mailing Address - Fax:
Practice Address - Street 1:3331 PLEASANT VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-4311
Practice Address - Country:US
Practice Address - Phone:814-942-1081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-10
Last Update Date:2016-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP450963183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist