Provider Demographics
NPI:1093435620
Name:TRAN, IVY THAO (PHARMD)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:THAO
Last Name:TRAN
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 1:10621 BOLSA AVE APT 41
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-5221
Mailing Address - Country:US
Mailing Address - Phone:714-989-0248
Mailing Address - Fax:
Practice Address - Street 1:3300 S BRISTOL ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-7246
Practice Address - Country:US
Practice Address - Phone:714-641-6604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86478183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist