Provider Demographics
NPI:1407922214
Name:FAGAN, THOMAS
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:FAGAN
Suffix:
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 1:12705 CLEARWATER DRIVE
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114
Mailing Address - Country:US
Mailing Address - Phone:804-675-5298
Mailing Address - Fax:804-675-5006
Practice Address - Street 1:1201 BROADWALK BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23249
Practice Address - Country:US
Practice Address - Phone:804-675-5298
Practice Address - Fax:804-675-5006
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202007681183500000X
NJ28RI01782400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist