Healthcare Provider Details

I. General information

NPI: 1902296098
Provider Name (Legal Business Name): DR. LAWRENCE JACK THOMAS III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2015
Last Update Date: 01/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 N MAIN ST
SUFFOLK VA
23434-4426
US

IV. Provider business mailing address

515 N MAIN ST
SUFFOLK VA
23434-4426
US

V. Phone/Fax

Practice location:
  • Phone: 757-539-9992
  • Fax:
Mailing address:
  • Phone: 757-539-9992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202213249
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: