Provider Demographics
NPI:1104548999
Name:BODENDORFER, THOMAS WALTER (PHARMD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WALTER
Last Name:BODENDORFER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28053 SUNSET BLVD W
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-7016
Mailing Address - Country:US
Mailing Address - Phone:248-252-9720
Mailing Address - Fax:
Practice Address - Street 1:28053 SUNSET BLVD W
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-7016
Practice Address - Country:US
Practice Address - Phone:248-252-9720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020219661835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI87-2462706OtherLARA STATE MICHIGAN SMALL BUSINESS LICENSING