Healthcare Provider Details

I. General information

NPI: 1548867914
Provider Name (Legal Business Name): DANH CANH THACH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 N BROAD ST
PHILADELPHIA PA
19141-1931
US

IV. Provider business mailing address

5011 RORER ST
PHILADELPHIA PA
19120-4013
US

V. Phone/Fax

Practice location:
  • Phone: 215-924-9645
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP455090
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: