Provider Demographics
NPI:1104128289
Name:SIMPSON, THOMAS RUSSEL III
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RUSSEL
Last Name:SIMPSON
Suffix:III
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 1:10612 BLACKHAWK CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-4185
Mailing Address - Country:US
Mailing Address - Phone:209-888-5780
Mailing Address - Fax:
Practice Address - Street 1:10612 BLACKHAWK CT
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-4185
Practice Address - Country:US
Practice Address - Phone:209-888-5780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26687183500000X
NV05486183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist