Provider Demographics
NPI:1659425577
Name:MINI THUONG XA PHARMACY INC
Entity Type:Organization
Organization Name:MINI THUONG XA PHARMACY INC
Other - Org Name:MINI THUONG XA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:773-230-2699
Mailing Address - Street 1:PO BOX 408975
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-0023
Mailing Address - Country:US
Mailing Address - Phone:773-728-1007
Mailing Address - Fax:773-728-7267
Practice Address - Street 1:1069 W ARGYLE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-3707
Practice Address - Country:US
Practice Address - Phone:773-728-1007
Practice Address - Fax:773-728-7267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
IL0540093213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2022077OtherPK
2022077OtherPK
IL=========001Medicaid