Provider Demographics
NPI:1417239773
Name:PHAN, THAO NGUYEN THI (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:THAO NGUYEN
Middle Name:THI
Last Name:PHAN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:DR
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARM D
Mailing Address - Street 1:3605 NW 175TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-6901
Mailing Address - Country:US
Mailing Address - Phone:405-513-2037
Mailing Address - Fax:
Practice Address - Street 1:15100 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-1108
Practice Address - Country:US
Practice Address - Phone:405-330-3742
Practice Address - Fax:405-330-5747
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13346183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist