Provider Demographics
NPI:1407579386
Name:TOM, PETER (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:TOM
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 1:1146 N CENTRAL AVE # 429
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-2506
Mailing Address - Country:US
Mailing Address - Phone:818-388-9521
Mailing Address - Fax:
Practice Address - Street 1:1036 CALLE CONTENTO
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-3017
Practice Address - Country:US
Practice Address - Phone:818-244-8357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37404183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist