Provider Demographics
NPI:1962768069
Name:CAMPBELL, THOMAS RAYMOND (R PH)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:RAYMOND
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-4444
Mailing Address - Country:US
Mailing Address - Phone:318-424-0896
Mailing Address - Fax:318-424-0897
Practice Address - Street 1:510 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-4444
Practice Address - Country:US
Practice Address - Phone:318-424-0896
Practice Address - Fax:318-424-0897
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13420183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA13420OtherPHARMACIST CERTIFICATE NUMBER