Provider Demographics
NPI:1053937458
Name:MAI, THAO PHUONG NGUYEN (PHARMD)
Entity type:Individual
Prefix:
First Name:THAO
Middle Name:PHUONG NGUYEN
Last Name:MAI
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 1:18302 RAIN CIR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1076
Mailing Address - Country:US
Mailing Address - Phone:714-717-1894
Mailing Address - Fax:949-453-9235
Practice Address - Street 1:16300 SAND CANYON AVE STE 101
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3704
Practice Address - Country:US
Practice Address - Phone:949-453-9789
Practice Address - Fax:949-453-9235
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-22
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50305183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist