Provider Demographics
NPI:1104931146
Name:R THOMAS BARTHOLOMEW
Entity type:Organization
Organization Name:R THOMAS BARTHOLOMEW
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:BARTHOLOMEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-598-4187
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:FAULKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57438-0070
Mailing Address - Country:US
Mailing Address - Phone:605-598-4187
Mailing Address - Fax:605-598-6772
Practice Address - Street 1:118 8TH AVE S
Practice Address - Street 2:
Practice Address - City:FAULKTON
Practice Address - State:SD
Practice Address - Zip Code:57438-2115
Practice Address - Country:US
Practice Address - Phone:605-598-4187
Practice Address - Fax:605-598-6772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 333600000X
SD10000093336L0003X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4301280OtherOTHER ID NUMBER
4301280OtherOTHER ID NUMBER-COMMERCIAL NUMBER
SD8501540Medicaid
SD0946570001Medicare NSC