Provider Demographics
NPI:1972953024
Name:THEMAS, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:THEMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 1ST STREET A
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-7728
Mailing Address - Country:US
Mailing Address - Phone:309-797-9286
Mailing Address - Fax:300-979-7019
Practice Address - Street 1:2014 1ST STREET A
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-7728
Practice Address - Country:US
Practice Address - Phone:309-797-9286
Practice Address - Fax:309-797-0199
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051030295183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist