Provider Demographics
NPI:1710526215
Name:GANTENBEIN, THOMAS RICHARD
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:RICHARD
Last Name:GANTENBEIN
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 1:111 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS JUNCTION
Mailing Address - State:IA
Mailing Address - Zip Code:52738-1014
Mailing Address - Country:US
Mailing Address - Phone:319-728-3144
Mailing Address - Fax:319-728-3156
Practice Address - Street 1:111 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS JUNCTION
Practice Address - State:IA
Practice Address - Zip Code:52738-1014
Practice Address - Country:US
Practice Address - Phone:319-728-3144
Practice Address - Fax:319-728-3156
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18539183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist