Provider Demographics
NPI:1477839793
Name:TA, KHANH (RPH)
Entity Type:Individual
Prefix:
First Name:KHANH
Middle Name:
Last Name:TA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6885 N WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5949
Mailing Address - Country:US
Mailing Address - Phone:559-322-0698
Mailing Address - Fax:559-322-4159
Practice Address - Street 1:6885 N WILLOW AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5949
Practice Address - Country:US
Practice Address - Phone:559-322-0698
Practice Address - Fax:559-322-4159
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48604183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist