Provider Demographics
NPI:1144472358
Name:THOMAS, VARGHESE K (RPH)
Entity type:Individual
Prefix:
First Name:VARGHESE
Middle Name:K
Last Name:THOMAS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEWYORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031
Mailing Address - Country:US
Mailing Address - Phone:212-283-6623
Mailing Address - Fax:212-283-5764
Practice Address - Street 1:3415 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEWYORK
Practice Address - State:NY
Practice Address - Zip Code:10031
Practice Address - Country:US
Practice Address - Phone:212-283-6623
Practice Address - Fax:212-283-5764
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0391221183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1194861104Medicaid