Provider Demographics
NPI:1790403558
Name:PHAN, THAO THANH (RPH)
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:THANH
Last Name:PHAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11350 WICKERSHAM BLVD
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-6979
Mailing Address - Country:US
Mailing Address - Phone:402-881-3687
Mailing Address - Fax:402-881-3533
Practice Address - Street 1:11350 WICKERSHAM BLVD
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:NE
Practice Address - Zip Code:68028-6979
Practice Address - Country:US
Practice Address - Phone:402-881-3687
Practice Address - Fax:402-881-3533
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17643183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist