Healthcare Provider Details

I. General information

NPI: 1194441477
Provider Name (Legal Business Name): MR. THOMAS RAYMOND DOUGHERTY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W 15TH ST
HAZLETON PA
18201-2783
US

IV. Provider business mailing address

901 W 15TH ST
HAZLETON PA
18201-2783
US

V. Phone/Fax

Practice location:
  • Phone: 570-708-4690
  • Fax: 833-481-3867
Mailing address:
  • Phone: 570-708-4690
  • Fax: 833-481-3867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP034664L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: