Provider Demographics
NPI:1518929785
Name:THOMAS PHARMACY GARDINER CENTER LLC
Entity Type:Organization
Organization Name:THOMAS PHARMACY GARDINER CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-428-5977
Mailing Address - Street 1:PO BOX 4111
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-4111
Mailing Address - Country:US
Mailing Address - Phone:601-428-5977
Mailing Address - Fax:601-428-7150
Practice Address - Street 1:170 LEONTYNE PRICE BLVD
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4428
Practice Address - Country:US
Practice Address - Phone:601-428-5977
Practice Address - Fax:601-428-7150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS5123500001332B00000X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330692Medicaid
MS01454526Medicaid
MS01454526Medicaid