Provider Demographics
NPI:1902427610
Name:KIM, MAI THANH (PHARMD)
Entity Type:Individual
Prefix:
First Name:MAI
Middle Name:THANH
Last Name:KIM
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 1:3001 MATLOCK RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3302
Mailing Address - Country:US
Mailing Address - Phone:817-473-0081
Mailing Address - Fax:
Practice Address - Street 1:3001 MATLOCK RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3302
Practice Address - Country:US
Practice Address - Phone:817-473-0081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-04
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47461183500000X, 1835P0018X
TX61506711835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care