Provider Demographics
NPI:1407124027
Name:THOMAS, OLLIE T III
Entity Type:Individual
Prefix:MR
First Name:OLLIE
Middle Name:T
Last Name:THOMAS
Suffix:III
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 1:830 N ELMER ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFITH
Mailing Address - State:IN
Mailing Address - Zip Code:46319-2384
Mailing Address - Country:US
Mailing Address - Phone:219-670-5637
Mailing Address - Fax:
Practice Address - Street 1:3564 RIDGE RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-3315
Practice Address - Country:US
Practice Address - Phone:708-895-2697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051035649183500000X
IN26017552A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist