Provider Demographics
NPI:1427555697
Name:THIBEAULT, ANDREW (PHARMD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:THIBEAULT
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 1:512 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-3517
Mailing Address - Country:US
Mailing Address - Phone:360-426-3327
Mailing Address - Fax:360-427-5223
Practice Address - Street 1:512 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-3517
Practice Address - Country:US
Practice Address - Phone:360-426-3327
Practice Address - Fax:360-427-5223
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS54482183500000X
WAPH60849077183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist