Provider Demographics
NPI:1639042484
Name:MA, THAO
Entity type:Individual
Prefix:
First Name:THAO
Middle Name:
Last Name:MA
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 1:1537 SYLVAN WAY
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-4295
Mailing Address - Country:US
Mailing Address - Phone:669-245-8734
Mailing Address - Fax:
Practice Address - Street 1:2449 W KETTLEMAN LN
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4124
Practice Address - Country:US
Practice Address - Phone:209-367-7882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-27
Last Update Date:2025-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91546183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist