Healthcare Provider Details

I. General information

NPI: 1457918344
Provider Name (Legal Business Name): THANH LIU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2019
Last Update Date: 05/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1898 FORT RD
SHERIDAN WY
82801-8320
US

IV. Provider business mailing address

1898 FORT RD
SHERIDAN WY
82801-8320
US

V. Phone/Fax

Practice location:
  • Phone: 307-675-3601
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number0002006792
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: