=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205590403
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS PHILLIPS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2021
-----------------------------------------------------
Last Update Date | 10/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 232 SMITHTOWN BLVD
-----------------------------------------------------
City | NESCONSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11767-2419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-265-3653
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 113 BILTMORE CIR
-----------------------------------------------------
City | HUNTINGTON STATION
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11746-1490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-494-2378
-----------------------------------------------------
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 | 039178
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------