Provider Demographics
NPI:1912441262
Name:MCDONALD, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:MCDONALD
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:PO BOX 952
Mailing Address - Street 2:
Mailing Address - City:BARNSTABLE
Mailing Address - State:MA
Mailing Address - Zip Code:02630-0952
Mailing Address - Country:US
Mailing Address - Phone:802-989-1416
Mailing Address - Fax:802-244-4334
Practice Address - Street 1:2 BOW LANE
Practice Address - Street 2:
Practice Address - City:BARNSTABLE
Practice Address - State:MA
Practice Address - Zip Code:02630-0952
Practice Address - Country:US
Practice Address - Phone:802-989-1416
Practice Address - Fax:802-244-4334
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH22588183500000X
CTPCT.0006887183500000X
VT033.0003431183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT033.0003431OtherVERMONT BOARD OF PHARMACY IDENTIFICATION
NYCPN202-0014OtherAPHA IMMUNIZATION CERTIFICATION (ALBANY COLLEGE OF PHARMACY)
CTPCT.0006887OtherCONNECTICUT BOARD OF PHARMACY REGISTRATION ID
MAPH22588OtherMASSACHUSETTS BOARD OF PHARMACY REGISTRATION ID