Provider Demographics
NPI:1619694825
Name:THAO, MAI HER
Entity Type:Individual
Prefix:
First Name:MAI
Middle Name:HER
Last Name:THAO
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 1:3001 HAHN DR APT 147
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6590
Mailing Address - Country:US
Mailing Address - Phone:530-693-8057
Mailing Address - Fax:
Practice Address - Street 1:1801 W 11TH ST
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3727
Practice Address - Country:US
Practice Address - Phone:209-830-2955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87096183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist