Healthcare Provider Details

I. General information

NPI: 1013254176
Provider Name (Legal Business Name): MR. BRANDON V THACH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BRANDON V THACH RPH

II. Dates (important events)

Enumeration Date: 01/09/2013
Last Update Date: 01/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 MARINER BLVD 160 MARINER BLVD
SPRING HILL FL
34609-5689
US

IV. Provider business mailing address

160 MARINER BLVD 160 MARINER BLVD
SPRING HILL FL
34609-5689
US

V. Phone/Fax

Practice location:
  • Phone: 352-688-2305
  • Fax: 352-666-2122
Mailing address:
  • Phone: 352-688-2305
  • Fax: 352-666-2122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS39614
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH23820
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: