Provider Demographics
NPI:1699022962
Name:STATZ, THOMAS JOSEPH
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOSEPH
Last Name:STATZ
Suffix:
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 1:2100 CALDWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-1510
Mailing Address - Country:US
Mailing Address - Phone:208-466-9616
Mailing Address - Fax:208-463-1724
Practice Address - Street 1:2100 CALDWELL BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1510
Practice Address - Country:US
Practice Address - Phone:208-466-9616
Practice Address - Fax:208-463-1724
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4647183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist