Healthcare Provider Details

I. General information

NPI: 1508079708
Provider Name (Legal Business Name): MR. THOMAS PAUL DADISMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S MAIN ST
PHILIPPI WV
26416-1240
US

IV. Provider business mailing address

303 S MAIN ST
PHILIPPI WV
26416-1240
US

V. Phone/Fax

Practice location:
  • Phone: 304-457-4233
  • Fax:
Mailing address:
  • Phone: 304-457-5207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4985
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: