Provider Demographics
NPI:1508499112
Name:SHEPPARD, THOMAS MAURICE (PHARMD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MAURICE
Last Name:SHEPPARD
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 1:192 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-3462
Mailing Address - Country:US
Mailing Address - Phone:920-921-5264
Mailing Address - Fax:920-921-2760
Practice Address - Street 1:192 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-3462
Practice Address - Country:US
Practice Address - Phone:920-921-5264
Practice Address - Fax:920-921-2760
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18580-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist