Healthcare Provider Details

I. General information

NPI: 1164069340
Provider Name (Legal Business Name): JOHNNY K THAI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 BROADWAY
OAKLAND CA
94611-5730
US

IV. Provider business mailing address

3600 BROADWAY
OAKLAND CA
94611-5730
US

V. Phone/Fax

Practice location:
  • Phone: 510-752-1000
  • Fax:
Mailing address:
  • Phone: 415-203-5142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number79259
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: