Basic Information
| Provider Information | |||||||||
| NPI: | 1295273662 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TA | ||||||||
| FirstName: | THANH | ||||||||
| MiddleName: | QUANG | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4897 LANLEE DR | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381254812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016066974 | ||||||||
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| Practice Location | |||||||||
| Address1: | 81 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019702714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787411200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2017 | ||||||||
| LastUpdateDate: | 02/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PH235901 | MA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.