Provider Demographics
NPI:1487941381
Name:STARK, THOMAS JACKSON JR (PHARMD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JACKSON
Last Name:STARK
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9006
Mailing Address - Country:US
Mailing Address - Phone:681-342-1580
Mailing Address - Fax:
Practice Address - Street 1:327 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9006
Practice Address - Country:US
Practice Address - Phone:681-342-1580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2013-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007086183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist