Provider Demographics
NPI:1376767343
Name:IDICULLA, THOMAS THUNDIYIL (RPH)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:THUNDIYIL
Last Name:IDICULLA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 STERLING DR
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2262
Mailing Address - Country:US
Mailing Address - Phone:860-716-5356
Mailing Address - Fax:
Practice Address - Street 1:759 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01199-1001
Practice Address - Country:US
Practice Address - Phone:860-716-5356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA26923183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist