Provider Demographics
NPI:1114564580
Name:PROFERA, THO (PHARMD)
Entity type:Individual
Prefix:
First Name:THO
Middle Name:
Last Name:PROFERA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH SIOUX CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68776-2427
Mailing Address - Country:US
Mailing Address - Phone:712-389-0932
Mailing Address - Fax:
Practice Address - Street 1:255 16TH ST SW
Practice Address - Street 2:
Practice Address - City:SIOUX CENTER
Practice Address - State:IA
Practice Address - Zip Code:51250-2959
Practice Address - Country:US
Practice Address - Phone:712-722-2326
Practice Address - Fax:712-722-2589
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23457183500000X
NE16241183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist