Provider Demographics
NPI:1083900369
Name:RUSTAMAN, THANH THANH DU (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:THANH
Middle Name:THANH DU
Last Name:RUSTAMAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12738 GRAND ELM ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-4452
Mailing Address - Country:US
Mailing Address - Phone:301-515-8070
Mailing Address - Fax:
Practice Address - Street 1:5700 BOU AVENUE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852
Practice Address - Country:US
Practice Address - Phone:301-945-0019
Practice Address - Fax:301-945-0019
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-24
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16244183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist