Provider Demographics
NPI:1679987697
Name:THANASACK, BOON
Entity Type:Individual
Prefix:DR
First Name:BOON
Middle Name:
Last Name:THANASACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 CANDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-2902
Mailing Address - Country:US
Mailing Address - Phone:614-204-1855
Mailing Address - Fax:
Practice Address - Street 1:208 CANDLEWOOD DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2902
Practice Address - Country:US
Practice Address - Phone:614-204-1855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY015233183500000X
OH03230261-2183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist