Provider Demographics
NPI:1598032583
Name:THANTRONG, KATI
Entity Type:Individual
Prefix:
First Name:KATI
Middle Name:
Last Name:THANTRONG
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 1:4550 ATLANTIC AVE.
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4550 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-1513
Practice Address - Country:US
Practice Address - Phone:800-834-8778
Practice Address - Fax:800-834-4333
Is Sole Proprietor?:No
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52883183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist