Provider Demographics
NPI:1134450570
Name:MCCORMACK, THOMAS BERNARD JR (RPH)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:BERNARD
Last Name:MCCORMACK
Suffix:JR
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 1:210 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1914
Mailing Address - Country:US
Mailing Address - Phone:262-763-7177
Mailing Address - Fax:262-763-9806
Practice Address - Street 1:210 S PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1914
Practice Address - Country:US
Practice Address - Phone:262-763-7177
Practice Address - Fax:262-763-9806
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11282-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist