Provider Demographics
NPI:1942751011
Name:DOLPH, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:DOLPH
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:THOMAS
Other - Middle Name:HOWARD
Other - Last Name:DOLPH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:6890 1ST ST W
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-5707
Mailing Address - Country:US
Mailing Address - Phone:406-301-3436
Mailing Address - Fax:
Practice Address - Street 1:167 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045
Practice Address - Country:US
Practice Address - Phone:928-283-2432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3946183500000X
NV15100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT3946OtherPHARMACIST LICENSE
NV15100OtherPHARMACIST LICENSE