Provider Demographics
NPI:1043814171
Name:DELLAVILLA, THOMAS (PHARMD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:DELLAVILLA
Suffix:
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 1:6336 OAKLANDON RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-2959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4750 E 450 S
Practice Address - Street 2:
Practice Address - City:WHITESTOWN
Practice Address - State:IN
Practice Address - Zip Code:46075-8404
Practice Address - Country:US
Practice Address - Phone:877-732-3431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26028750A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
26028750AOtherPHARMACY LICENSE