Provider Demographics
NPI:1477801066
Name:THACKER, DAVID LEO (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LEO
Last Name:THACKER
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 1:6101 N. KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-2488
Mailing Address - Country:US
Mailing Address - Phone:317-454-7505
Mailing Address - Fax:317-454-7515
Practice Address - Street 1:6101 N. KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-2488
Practice Address - Country:US
Practice Address - Phone:317-454-7505
Practice Address - Fax:317-454-7515
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202206395183500000X
WVRP0006855183500000X
IN26023537A1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist