Provider Demographics
NPI:1093812927
Name:TAN THAI INC
Entity Type:Organization
Organization Name:TAN THAI INC
Other - Org Name:OLD VILLAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:TAN
Authorized Official - Middle Name:
Authorized Official - Last Name:THAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-853-3498
Mailing Address - Street 1:978 GALLOWAY RD
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119-8293
Mailing Address - Country:US
Mailing Address - Phone:614-853-3498
Mailing Address - Fax:614-853-4022
Practice Address - Street 1:978 GALLOWAY RD
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:OH
Practice Address - Zip Code:43119-8293
Practice Address - Country:US
Practice Address - Phone:614-853-3498
Practice Address - Fax:614-853-4022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
OH0213304503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2078707OtherPK
OH2332738Medicaid
4742670001Medicare NSC
3670785OtherOTHER ID NUMBER