Provider Demographics
NPI:1639324502
Name:YATES, THEA MARIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:THEA
Middle Name:MARIE
Last Name:YATES
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-1595
Mailing Address - Country:US
Mailing Address - Phone:802-388-3784
Mailing Address - Fax:802-388-1720
Practice Address - Street 1:99 MAPLE ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-1595
Practice Address - Country:US
Practice Address - Phone:802-388-3784
Practice Address - Fax:802-388-1720
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033-0003732183500000X
FLPS35704183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist