Provider Demographics
NPI:1619252954
Name:THOMAS, MIKE (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 S WALL ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3023
Mailing Address - Country:US
Mailing Address - Phone:618-457-4104
Mailing Address - Fax:618-529-3603
Practice Address - Street 1:206 S WALL ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3023
Practice Address - Country:US
Practice Address - Phone:618-457-4104
Practice Address - Fax:618-529-3603
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051031330183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist