Provider Demographics
NPI:1205280443
Name:JOSEPH, TOM
Entity type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:JOSEPH
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 1:2698 N GALLOWAY AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6390
Mailing Address - Country:US
Mailing Address - Phone:972-270-5600
Mailing Address - Fax:
Practice Address - Street 1:2698 N GALLOWAY AVE STE 108
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6390
Practice Address - Country:US
Practice Address - Phone:972-270-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX57328183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist