Provider Demographics
NPI:1710200357
Name:CAMPBELL, THOMAS MITCHELL (RPH)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MITCHELL
Last Name:CAMPBELL
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 1:193 HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:POMFRET CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06259-1712
Mailing Address - Country:US
Mailing Address - Phone:860-655-5259
Mailing Address - Fax:
Practice Address - Street 1:193 HAMPTON RD
Practice Address - Street 2:
Practice Address - City:POMFRET CENTER
Practice Address - State:CT
Practice Address - Zip Code:06259-1712
Practice Address - Country:US
Practice Address - Phone:860-655-5259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7221183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004169927Medicaid
CT004169927Medicaid