Provider Demographics
NPI:1457690075
Name:MAI, VAN H (RPH)
Entity type:Individual
Prefix:
First Name:VAN
Middle Name:H
Last Name:MAI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:859 SE 1ST TER
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-1201
Mailing Address - Country:US
Mailing Address - Phone:239-574-2846
Mailing Address - Fax:239-574-2846
Practice Address - Street 1:859 SE 1ST TER
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-1201
Practice Address - Country:US
Practice Address - Phone:239-574-2846
Practice Address - Fax:239-574-2846
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS19202183500000X
FLPH19068183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist