Provider Demographics
NPI:1750714663
Name:MAI, KHANH
Entity type:Individual
Prefix:MRS
First Name:KHANH
Middle Name:
Last Name:MAI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 OLD OAK DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77632-1320
Mailing Address - Country:US
Mailing Address - Phone:409-338-2893
Mailing Address - Fax:
Practice Address - Street 1:1624 N BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-2139
Practice Address - Country:US
Practice Address - Phone:225-644-7528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018877183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist