=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780003491
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABISH THOMAS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2014
-----------------------------------------------------
Last Update Date | 05/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 740 W MAIN ST UNIT 5
-----------------------------------------------------
City | HAINES CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33844-4119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-419-7777
-----------------------------------------------------
Fax | 863-419-7772
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 740 W MAIN ST UNIT 5
-----------------------------------------------------
City | HAINES CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33844-4119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-419-7777
-----------------------------------------------------
Fax | 863-419-7772
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PS39557
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 057921
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------