Basic Information
Provider Information
NPI: 1003149857
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: THACKER
FirstName: BRIDGETTE
MiddleName: RENEE'
NamePrefix:  
NameSuffix:  
Credential: PHARMD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 488 HURRICANE CRK
Address2:  
City: KIMPER
State: KY
PostalCode: 415396204
CountryCode: US
TelephoneNumber: 6066319786
FaxNumber:  
Practice Location
Address1: 11349 STATE HIGHWAY 1056
Address2:  
City: MCCARR
State: KY
PostalCode: 41544
CountryCode: US
TelephoneNumber: 6064279007
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/11/2009
LastUpdateDate: 09/11/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X014586KYY Pharmacy Service ProvidersPharmacist 

No ID Information.


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