Provider Demographics
NPI:1518658715
Name:BAO, NINA (PHTC)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:BAO
Suffix:
Gender:F
Credentials:PHTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 E THELBORN ST
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-1210
Mailing Address - Country:US
Mailing Address - Phone:626-377-1655
Mailing Address - Fax:
Practice Address - Street 1:405 W IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-4818
Practice Address - Country:US
Practice Address - Phone:714-529-2176
Practice Address - Fax:714-529-8834
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90817183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician