Provider Demographics
NPI:1760142764
Name:NOLL, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:NOLL
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 1:7250 CALLON AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WI
Mailing Address - Zip Code:54476-3208
Mailing Address - Country:US
Mailing Address - Phone:262-210-6456
Mailing Address - Fax:
Practice Address - Street 1:2806 SCHOFIELD AVE
Practice Address - Street 2:
Practice Address - City:SCHOFIELD
Practice Address - State:WI
Practice Address - Zip Code:54476-2431
Practice Address - Country:US
Practice Address - Phone:715-359-3194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-19
Last Update Date:2021-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21057-401835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist