Provider Demographics
NPI:1154921724
Name:THAMES, PAUL LYNDON JR
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:LYNDON
Last Name:THAMES
Suffix:JR
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 1:648 GORDON AVE
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-4110
Mailing Address - Country:US
Mailing Address - Phone:773-972-4268
Mailing Address - Fax:
Practice Address - Street 1:3320 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-4531
Practice Address - Country:US
Practice Address - Phone:708-652-8091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051300182183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist