Healthcare Provider Details

I. General information

NPI: 1295825727
Provider Name (Legal Business Name): THOMAS SUTHERLAND RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 FIRST AVE S ILWACO PHARMACY
ILWACO WA
98624
US

IV. Provider business mailing address

101 FIRST AVE S ILWACO PHARMACY
ILWACO WA
98624
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-4802
  • Fax: 360-642-5133
Mailing address:
  • Phone: 360-642-4802
  • Fax: 360-642-5133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00013794
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: