Provider Demographics
NPI:1407859457
Name:MAGNIFICO, THOMAS A (RPH)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:A
Last Name:MAGNIFICO
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 1:5455 RANGER HILLS DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6443
Mailing Address - Country:US
Mailing Address - Phone:616-498-4432
Mailing Address - Fax:
Practice Address - Street 1:4021 CASCADE RD SE
Practice Address - Street 2:SUITE 50
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2177
Practice Address - Country:US
Practice Address - Phone:616-974-9792
Practice Address - Fax:616-464-3469
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030831183500000X
PARP032139L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist