Provider Demographics
NPI: | 1336548569 |
---|---|
Name: | THUMAR, RICKY BALUBHAI (PHARMD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | RICKY |
Middle Name: | BALUBHAI |
Last Name: | THUMAR |
Suffix: | |
Gender: | M |
Credentials: | PHARMD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 637 WASHINGTON ST |
Mailing Address - Street 2: | |
Mailing Address - City: | DORCHESTER |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 02124-3510 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 617-822-8374 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 637 WASHINGTON ST |
Practice Address - Street 2: | |
Practice Address - City: | DORCHESTER |
Practice Address - State: | MA |
Practice Address - Zip Code: | 02124-3510 |
Practice Address - Country: | US |
Practice Address - Phone: | 617-822-8374 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2014-08-13 |
Last Update Date: | 2019-06-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MA | PH234175 | 183500000X, 1835P2201X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1835P2201X | Pharmacy Service Providers | Pharmacist | Ambulatory Care |
No | 183500000X | Pharmacy Service Providers | Pharmacist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MA | MCS000011P | Other | CONTROLLED SUBSTANCE REGISTRATION (MASSACHUSETTS) |
MA | PH234175 | Other | PHARMACIST STATE LICENSE (MASSACHUSETTS) |