Provider Demographics
NPI:1487255865
Name:THOMPSON, KATIE CORBITT
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:CORBITT
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 W STATE HIGHWAY 114
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-8652
Mailing Address - Country:US
Mailing Address - Phone:817-416-0561
Mailing Address - Fax:
Practice Address - Street 1:1701 W STATE HIGHWAY 114
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-8652
Practice Address - Country:US
Practice Address - Phone:817-416-0561
Practice Address - Fax:817-416-0642
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX57278183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist