MEDICARE: CHANNING THACKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	RP450963	PA

General Provider Information

NPI Number	:	1376090076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANNING THACKER

Provider Business Mailing Address
First Line	:	1001 HENCH CIR APT 5
Second Line	:
City	:	ALTOONA
State	:	PA
Zip	:	16602-6919
Country	:	US
Telephone Number	:	606-253-1260
Fax Number	:

Provider Business Practice Location Address
First Line	:	3331 PLEASANT VALLEY BLVD
Second Line	:
City	:	ALTOONA
State	:	PA
Zip	:	16602-4311
Country	:	US
Telephone Number	:	814-942-1081
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2016
Last Update Date	:	09/10/2016

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Directions to “ CHANNING THACKER ” Practice Location

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