Provider Demographics
NPI:1851772479
Name:HALTOM, THOMAS (RPH)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:HALTOM
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 1:6308 LAKE WORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-3602
Mailing Address - Country:US
Mailing Address - Phone:817-237-8128
Mailing Address - Fax:817-237-0110
Practice Address - Street 1:6308 LAKE WORTH BLVD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3602
Practice Address - Country:US
Practice Address - Phone:817-237-8128
Practice Address - Fax:817-237-0110
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14625183500000X
TX24478183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist