Provider Demographics
NPI:1407369275
Name:TA, TONY MINH (BS IN PHARMACY)
Entity Type:Individual
Prefix:MR
First Name:TONY
Middle Name:MINH
Last Name:TA
Suffix:
Gender:M
Credentials:BS IN PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 W SHAW AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-3726
Mailing Address - Country:US
Mailing Address - Phone:559-298-0600
Mailing Address - Fax:559-325-2226
Practice Address - Street 1:159 W SHAW AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-3726
Practice Address - Country:US
Practice Address - Phone:559-298-0600
Practice Address - Fax:559-325-2226
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH59540183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1255687489Medicaid