Provider Demographics
NPI:1790149854
Name:KOONTZ, THOMAS (RPH)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:KOONTZ
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 1:5551 CORPORATE BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-2567
Mailing Address - Country:US
Mailing Address - Phone:225-924-1930
Mailing Address - Fax:877-625-3210
Practice Address - Street 1:5551 CORPORATE BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-2567
Practice Address - Country:US
Practice Address - Phone:225-924-1930
Practice Address - Fax:877-625-3210
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39766183500000X
LAPST.018717183500000X
WVRP0008392183500000X
MD21574183500000X
OH03226166183500000X
PARP033607L183500000X
MO2011017105183500000X
TN0000033370183500000X
MST-12461183500000X
ARPD10890183500000X
VA0202209407183500000X
AL19023183500000X
KY014430183500000X
MI5302043049183500000X
OR0011532183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist