Provider Demographics
NPI:1972904530
Name:PHAN, THAO (PHARMD)
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22006 40TH PL S
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-8423
Mailing Address - Country:US
Mailing Address - Phone:206-992-3669
Mailing Address - Fax:
Practice Address - Street 1:4025 DELRIDGE WAY SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98106-1249
Practice Address - Country:US
Practice Address - Phone:206-767-0333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60475891183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist