Provider Demographics
NPI:1083629687
Name:TAN TAN PHARMACY
Entity Type:Organization
Organization Name:TAN TAN PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:DAO ANH
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-580-1777
Mailing Address - Street 1:12002 VETERANS MEMORIAL DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77067-1089
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12002 VETERANS MEMORIAL DR
Practice Address - Street 2:SUITE C
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77067-1089
Practice Address - Country:US
Practice Address - Phone:281-580-1777
Practice Address - Fax:281-580-6725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16634333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144281Medicaid
4594760OtherOTHER ID NUMBER-COMMERCIAL NUMBER