Provider Demographics
NPI:1407973308
Name:STREETER, THOMAS (RPH)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:STREETER
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 1:21082 PIONEER PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5500
Mailing Address - Country:US
Mailing Address - Phone:315-788-0146
Mailing Address - Fax:315-788-0620
Practice Address - Street 1:21082 PIONEER PLAZA DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5500
Practice Address - Country:US
Practice Address - Phone:315-788-0146
Practice Address - Fax:315-788-0620
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033676183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist