Provider Demographics
NPI:1639459365
Name:THANICATT, TONY M (RPH)
Entity Type:Individual
Prefix:MR
First Name:TONY
Middle Name:M
Last Name:THANICATT
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 N BLACK HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-3957
Mailing Address - Country:US
Mailing Address - Phone:856-228-1368
Mailing Address - Fax:856-228-1506
Practice Address - Street 1:625 N BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:BLACKWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08012-3957
Practice Address - Country:US
Practice Address - Phone:856-228-1368
Practice Address - Fax:856-228-1506
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02733300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist