Provider Demographics
NPI:1417087891
Name:KAVANAGH, THOMAS E (RP)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:E
Last Name:KAVANAGH
Suffix:
Gender:M
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:NAZARETH
Mailing Address - State:PA
Mailing Address - Zip Code:18064-2116
Mailing Address - Country:US
Mailing Address - Phone:610-759-3240
Mailing Address - Fax:610-746-0946
Practice Address - Street 1:19 S BROAD ST
Practice Address - Street 2:
Practice Address - City:NAZARETH
Practice Address - State:PA
Practice Address - Zip Code:18064-2116
Practice Address - Country:US
Practice Address - Phone:610-759-3240
Practice Address - Fax:610-746-0946
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP030677L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP030677LOtherSTATE LICENSE