Provider Demographics
NPI:1477632859
Name:WINNINGHAM, THOMAS E (PD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:WINNINGHAM
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:WINNINGHAM
Other - Middle Name:DRUG
Other - Last Name:STORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:232 W MAIN ST
Mailing Address - City:BRADFORD
Mailing Address - State:AR
Mailing Address - Zip Code:72020-0130
Mailing Address - Country:US
Mailing Address - Phone:501-344-2763
Mailing Address - Fax:501-344-8383
Practice Address - Street 1:232 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:AR
Practice Address - Zip Code:72020-0130
Practice Address - Country:US
Practice Address - Phone:501-344-2763
Practice Address - Fax:501-344-8383
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-04
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD05283183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR118686716OtherMEDICAID DME
AR100499407Medicaid
0150760001Medicare ID - Type Unspecified