Provider Demographics
NPI:1619579588
Name:TRAN, THAO
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:
Last Name:TRAN
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 1:4200 SALEM RD
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-4533
Mailing Address - Country:US
Mailing Address - Phone:678-212-3202
Mailing Address - Fax:678-212-3196
Practice Address - Street 1:4200 SALEM RD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-4533
Practice Address - Country:US
Practice Address - Phone:678-212-3202
Practice Address - Fax:678-212-3196
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-14
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH027700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist