Provider Demographics
NPI:1619578630
Name:PHILLIPS, THEODORE BANKS JR
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:BANKS
Last Name:PHILLIPS
Suffix:JR
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 1:2801 E MARKET ST BLDG B
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-2406
Mailing Address - Country:US
Mailing Address - Phone:717-751-0494
Mailing Address - Fax:717-751-0696
Practice Address - Street 1:2801 E MARKET ST BLDG B
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-2406
Practice Address - Country:US
Practice Address - Phone:717-751-0494
Practice Address - Fax:717-751-0696
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP044677R183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist