Healthcare Provider Details

I. General information

NPI: 1154737013
Provider Name (Legal Business Name): TOM VANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2014
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 W OLIVE AVE
MADERA CA
93637-5402
US

IV. Provider business mailing address

2384 S PLAYA AVE
FRESNO CA
93727-6362
US

V. Phone/Fax

Practice location:
  • Phone: 559-674-2182
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number68861
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: