Healthcare Provider Details

I. General information

NPI: 1114547007
Provider Name (Legal Business Name): MAI HOANG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2020
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1471 ROBERT ST S
WEST SAINT PAUL MN
55118-3141
US

IV. Provider business mailing address

1471 ROBERT ST S
WEST SAINT PAUL MN
55118-3141
US

V. Phone/Fax

Practice location:
  • Phone: 651-552-6029
  • Fax:
Mailing address:
  • Phone: 651-552-6029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number123863
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: