Provider Demographics
NPI:1629227137
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 1:141 KOESTER ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14220-1447
Mailing Address - Country:US
Mailing Address - Phone:716-553-5456
Mailing Address - Fax:
Practice Address - Street 1:355 ORCHARD PARK RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-2634
Practice Address - Country:US
Practice Address - Phone:716-517-3003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052843183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY052843Medicaid