Provider Demographics
NPI:1851816391
Name:JORGENSEN, THOMAS ROBERT
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ROBERT
Last Name:JORGENSEN
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 1:2700 G RD APT 7D
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-1408
Mailing Address - Country:US
Mailing Address - Phone:605-610-6664
Mailing Address - Fax:
Practice Address - Street 1:200 ROOD AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-7819
Practice Address - Country:US
Practice Address - Phone:970-241-2278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-05
Last Update Date:2017-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00218553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy