Provider Demographics
NPI:1902235229
Name:THOMAS, LARRY IV
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:THOMAS
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 1ST ST
Mailing Address - Street 2:
Mailing Address - City:KEOSAUQUA
Mailing Address - State:IA
Mailing Address - Zip Code:52565-7701
Mailing Address - Country:US
Mailing Address - Phone:319-293-3128
Mailing Address - Fax:319-293-3853
Practice Address - Street 1:601 1ST ST
Practice Address - Street 2:
Practice Address - City:KEOSAUQUA
Practice Address - State:IA
Practice Address - Zip Code:52565-7701
Practice Address - Country:US
Practice Address - Phone:319-293-3128
Practice Address - Fax:319-293-3853
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1486183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist