Provider Demographics
NPI:1700067949
Name:THIBAULT, VICKI
Entity Type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:
Last Name:THIBAULT
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 1:695 E JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-7502
Mailing Address - Country:US
Mailing Address - Phone:631-425-6210
Mailing Address - Fax:631-425-6217
Practice Address - Street 1:695 E JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-7502
Practice Address - Country:US
Practice Address - Phone:631-425-6210
Practice Address - Fax:631-425-6217
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046779183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01776847Medicaid