=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154881134
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN MICHAEL THOMPSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2019
-----------------------------------------------------
Last Update Date | 03/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1911 MARSHA SHARP FWY
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79415-4036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-747-3454
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2813 PASADENA PL
-----------------------------------------------------
City | FLOWER MOUND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75022-5151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 64214
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------