Provider Demographics
NPI:1992762561
Name:PERCIVAL, THOMAS DONALD
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:DONALD
Last Name:PERCIVAL
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 1:11351 N MICKE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-9405
Mailing Address - Country:US
Mailing Address - Phone:209-367-5491
Mailing Address - Fax:
Practice Address - Street 1:7506 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-1929
Practice Address - Country:US
Practice Address - Phone:209-951-1051
Practice Address - Fax:209-951-8572
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32340183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist