Provider Demographics
NPI:1518295526
Name:THOMLINSON, JEFFERY DALE
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:DALE
Last Name:THOMLINSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6122 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581-7804
Mailing Address - Country:US
Mailing Address - Phone:281-412-4896
Mailing Address - Fax:
Practice Address - Street 1:6122 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-7804
Practice Address - Country:US
Practice Address - Phone:281-412-4896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34162183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX361924025Medicaid