Healthcare Provider Details

I. General information

NPI: 1518562206
Provider Name (Legal Business Name): CHANTHA MAO ZIPPAY RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3479 THOMASVILLE RD
TALLAHASSEE FL
32309-3425
US

IV. Provider business mailing address

691 VIOLET ST
TALLAHASSEE FL
32308-6244
US

V. Phone/Fax

Practice location:
  • Phone: 850-893-0459
  • Fax: 850-893-6381
Mailing address:
  • Phone: 850-309-7305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS0030867
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: