Provider Demographics
NPI:1619220001
Name:TA, THANH DAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:THANH
Middle Name:DAN
Last Name:TA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7110 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2014
Mailing Address - Country:US
Mailing Address - Phone:248-922-1231
Mailing Address - Fax:
Practice Address - Street 1:901 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1854
Practice Address - Country:US
Practice Address - Phone:310-857-8180
Practice Address - Fax:310-582-7405
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302039092183500000X
CA78498183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist