Provider Demographics
NPI:1992486526
Name:COLEMAN, THOMAS JAMES ROBERT
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JAMES ROBERT
Last Name:COLEMAN
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 1:4433 VANGUARD DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-6067
Mailing Address - Country:US
Mailing Address - Phone:920-459-9470
Mailing Address - Fax:
Practice Address - Street 1:4433 VANGUARD DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083-6067
Practice Address - Country:US
Practice Address - Phone:920-459-9470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22250-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist