Healthcare Provider Details

I. General information

NPI: 1407922214
Provider Name (Legal Business Name): MR. THOMAS FAGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 BROADWALK BLVD
RICHMOND VA
23249
US

IV. Provider business mailing address

12705 CLEARWATER DRIVE
MIDLOTHIAN VA
23114
US

V. Phone/Fax

Practice location:
  • Phone: 804-675-5298
  • Fax: 804-675-5006
Mailing address:
  • Phone: 804-675-5298
  • Fax: 804-675-5006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202007681
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI01782400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: