Provider Demographics
NPI:1679958417
Name:PHAM, THAO (PHARMD)
Entity type:Individual
Prefix:
First Name:THAO
Middle Name:
Last Name:PHAM
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 1:14400 JOHN HUMPHREY DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-2897
Mailing Address - Country:US
Mailing Address - Phone:708-460-4930
Mailing Address - Fax:708-460-4932
Practice Address - Street 1:14400 JOHN HUMPHREY DR
Practice Address - Street 2:SUITE 110
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-2897
Practice Address - Country:US
Practice Address - Phone:708-460-4930
Practice Address - Fax:708-460-4932
Is Sole Proprietor?:No
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.296467183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist