Provider Demographics
NPI:1053616581
Name:PHAT DAI TAI LLC
Entity type:Organization
Organization Name:PHAT DAI TAI LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-826-7748
Mailing Address - Street 1:13203 W PALO VERDE DR
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-8356
Mailing Address - Country:US
Mailing Address - Phone:623-826-7748
Mailing Address - Fax:623-535-9711
Practice Address - Street 1:2222 E HIGHLAND AVE STE 102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4874
Practice Address - Country:US
Practice Address - Phone:623-535-5822
Practice Address - Fax:623-535-9711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AZY0053323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0356938OtherNCPDP PROVIDER IDENTIFICATION NUMBER