Healthcare Provider Details

I. General information

NPI: 1821861675
Provider Name (Legal Business Name): THAO THI PHUONG HOANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2023
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6365 STAGECOACH DR
WEST DES MOINES IA
50266-8083
US

IV. Provider business mailing address

3843 122ND ST
URBANDALE IA
50323-2303
US

V. Phone/Fax

Practice location:
  • Phone: 515-453-2760
  • Fax:
Mailing address:
  • Phone: 515-918-6010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number24897
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: