MEDICARE: MR. TERRY CLARK THOMAS 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	PH00021826	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PH00021826	OTHER	WA	PHARMACY LICENSE

General Provider Information

NPI Number	:	1891792891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TERRY CLARK THOMAS RPH

Provider Business Mailing Address
First Line	:	5823 BOB GALBREATH RD
Second Line	:	PO BOX 946
City	:	CLINTON
State	:	WA
Zip	:	98236-9558
Country	:	US
Telephone Number	:	360-341-2276
Fax Number	:

Provider Business Practice Location Address
First Line	:	11042 SR 525
Second Line	:	SUITE 130
City	:	CLINTON
State	:	WA
Zip	:	98236-8618
Country	:	US
Telephone Number	:	360-341-3885
Fax Number	:	360-341-3886

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

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	07/08/2007

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