Provider Demographics
NPI:1699378364
Name:VAN, THU TRANG L (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:THU TRANG
Middle Name:L
Last Name:VAN
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8117 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:IL
Mailing Address - Zip Code:60459-1653
Mailing Address - Country:US
Mailing Address - Phone:708-527-8447
Mailing Address - Fax:
Practice Address - Street 1:11000 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5504
Practice Address - Country:US
Practice Address - Phone:708-346-0726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.303354183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist