Provider Demographics
NPI:1962717363
Name:HAYNES, THOMAS D (RPH)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:HAYNES
Suffix:
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 1:6010 RIVER ROAD CIR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4734
Mailing Address - Country:US
Mailing Address - Phone:318-797-9165
Mailing Address - Fax:
Practice Address - Street 1:1645 E BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5725
Practice Address - Country:US
Practice Address - Phone:318-797-9165
Practice Address - Fax:318-606-6577
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2023-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist