Provider Demographics
NPI:1790209252
Name:OUELLETTE, THOMAS ANTHONY
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ANTHONY
Last Name:OUELLETTE
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 1:96 GODEK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06451-5074
Mailing Address - Country:US
Mailing Address - Phone:203-213-9301
Mailing Address - Fax:
Practice Address - Street 1:649 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1082
Practice Address - Country:US
Practice Address - Phone:203-757-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0014200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist