Provider Demographics
NPI:1932723780
Name:TRAN, THAO
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:
Last Name:TRAN
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 1:12609 WINSTON AVE
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50323-2381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:IA
Practice Address - Zip Code:50213-8235
Practice Address - Country:US
Practice Address - Phone:641-342-1662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-07
Last Update Date:2020-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20618183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA20618OtherSTATE LICENSE