Provider Demographics
NPI:1144653148
Name:THAI, MAI PHUONG (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MAI
Middle Name:PHUONG
Last Name:THAI
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 1:1844 E ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-3868
Mailing Address - Country:US
Mailing Address - Phone:626-335-4777
Mailing Address - Fax:626-335-4774
Practice Address - Street 1:1844 E ROUTE 66
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-3868
Practice Address - Country:US
Practice Address - Phone:626-335-4777
Practice Address - Fax:626-335-4774
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55403183500000X, 1835P0018X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7051350001Medicare NSC