Provider Demographics
NPI:1336638998
Name:KODANI, ANN THI
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:THI
Last Name:KODANI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 FLETCHER PKWY
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-2522
Mailing Address - Country:US
Mailing Address - Phone:619-440-0848
Mailing Address - Fax:619-440-4047
Practice Address - Street 1:605 FLETCHER PKWY
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-2522
Practice Address - Country:US
Practice Address - Phone:619-440-0848
Practice Address - Fax:619-440-4047
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57730183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3203036Medicaid