MEDICARE: MR. THOMAS ALLEN MALLOW RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	03312042	OH

General Provider Information

NPI Number	:	1023490497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THOMAS ALLEN MALLOW RPH

Provider Business Mailing Address
First Line	:	6410 HERITAGE PARK BLVD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45424-1770
Country	:	US
Telephone Number	:	937-371-3662
Fax Number	:

Provider Business Practice Location Address
First Line	:	6410 HERITAGE PARK BLVD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45424-1770
Country	:	US
Telephone Number	:	937-371-3662
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2015
Last Update Date	:	06/22/2015

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