Provider Demographics
NPI:1417274325
Name:THAI, TRAM MONG
Entity Type:Individual
Prefix:MRS
First Name:TRAM
Middle Name:MONG
Last Name:THAI
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 1:2401 SWATARA ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-2036
Mailing Address - Country:US
Mailing Address - Phone:717-856-0330
Mailing Address - Fax:
Practice Address - Street 1:5600 CARLISLE PIKE # US11
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-2406
Practice Address - Country:US
Practice Address - Phone:717-856-0330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-02
Last Update Date:2010-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP045446L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP045446LOtherPHARMACIST LICENSE NUMBER
PARPI000205OtherIMMUNIZATION LICENSE NUMBER