Provider Demographics
NPI:1477141042
Name:THAO, KA BAO (PHARMD)
Entity type:Individual
Prefix:
First Name:KA
Middle Name:BAO
Last Name:THAO
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 1:268 N LOCAN AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93737-9748
Mailing Address - Country:US
Mailing Address - Phone:559-367-7620
Mailing Address - Fax:
Practice Address - Street 1:1794 ASHLAN AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-5190
Practice Address - Country:US
Practice Address - Phone:559-294-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83982183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist