Provider Demographics
NPI:1629353065
Name:WILLICK, THAO
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:
Last Name:WILLICK
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 1:750 N VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89501-1001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 N VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89501-1001
Practice Address - Country:US
Practice Address - Phone:775-337-8703
Practice Address - Fax:775-337-8730
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17589183500000X
MI5302032413183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist