Provider Demographics
NPI:1588038251
Name:THOMPSON, PORTIA DAWN
Entity Type:Individual
Prefix:DR
First Name:PORTIA
Middle Name:DAWN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WEST OUTER DR
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:78133-5164
Mailing Address - Country:US
Mailing Address - Phone:540-580-6797
Mailing Address - Fax:
Practice Address - Street 1:311 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FLOYD
Practice Address - State:VA
Practice Address - Zip Code:24091-2131
Practice Address - Country:US
Practice Address - Phone:540-580-6797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX55122183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist