Provider Demographics
NPI:1992160048
Name:VAN, THANH (PHARMD,)
Entity type:Individual
Prefix:MRS
First Name:THANH
Middle Name:
Last Name:VAN
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 1:9352 HUDSON DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-7933
Mailing Address - Country:US
Mailing Address - Phone:714-588-1838
Mailing Address - Fax:
Practice Address - Street 1:175 E 17TH ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3708
Practice Address - Country:US
Practice Address - Phone:949-631-9223
Practice Address - Fax:949-631-6907
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55410183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist