Provider Demographics
NPI:1760699250
Name:BALL, THOMAS P (RPH, CPH, CPE)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:BALL
Suffix:
Gender:M
Credentials:RPH, CPH, CPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 437
Mailing Address - Street 2:
Mailing Address - City:LAKE COMO
Mailing Address - State:FL
Mailing Address - Zip Code:32157-0437
Mailing Address - Country:US
Mailing Address - Phone:386-649-9354
Mailing Address - Fax:386-467-3112
Practice Address - Street 1:1115 N SUMMIT ST
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:FL
Practice Address - Zip Code:32112-1721
Practice Address - Country:US
Practice Address - Phone:386-698-4922
Practice Address - Fax:386-698-4903
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS15306183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPU 2508OtherCONSULTANT
FLPS15306OtherPHARMACIST