Provider Demographics
NPI:1972605822
Name:STANFORD, THOMAS RAY
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:RAY
Last Name:STANFORD
Suffix:
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 1:1030 DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:ELDORADO
Mailing Address - State:IL
Mailing Address - Zip Code:62930-3059
Mailing Address - Country:US
Mailing Address - Phone:618-268-6867
Mailing Address - Fax:
Practice Address - Street 1:1201 PINE ST
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-1634
Practice Address - Country:US
Practice Address - Phone:618-273-3361
Practice Address - Fax:618-273-2504
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist