Provider Demographics
NPI:1407342769
Name:SMITH, THOMAS ROBERT (PHARMD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ROBERT
Last Name:SMITH
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 1:11710 HEMINGWAY BAY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-8233
Mailing Address - Country:US
Mailing Address - Phone:856-693-2024
Mailing Address - Fax:
Practice Address - Street 1:1720 BEACON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4749
Practice Address - Country:US
Practice Address - Phone:856-693-2024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024785A1835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1300XPharmacy Service ProvidersPharmacistPsychiatric