Provider Demographics
NPI:1598158255
Name:HARRIS, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:R PH
Mailing Address - Street 1:2 CRESCENT DRIVE
Mailing Address - Street 2:
Mailing Address - City:WEST JEFFERSON
Mailing Address - State:NC
Mailing Address - Zip Code:28694
Mailing Address - Country:US
Mailing Address - Phone:336-246-2790
Mailing Address - Fax:336-246-2023
Practice Address - Street 1:2 CRESCENT DR
Practice Address - Street 2:
Practice Address - City:WEST JEFFERSON
Practice Address - State:NC
Practice Address - Zip Code:28694-7375
Practice Address - Country:US
Practice Address - Phone:336-246-2790
Practice Address - Fax:336-246-2023
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16359183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0055095Medicaid