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General NPI Number Information
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NPI Number | 1053616581
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Entity Type | Organization
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Legal Business Name | PHAT DAI TAI LLC
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Dates
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Enumeration Date | 01/13/2011
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Last Update Date | 01/13/2011
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Provider Practice Location Address
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Address Line | 2222 E HIGHLAND AVE STE 102
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City | PHOENIX
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State | AZ
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Zip | 85016-4874
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Country | US
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Telephone | 623-535-5822
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Fax | 623-535-9711
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Provider Business Mailing Address
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Address Line | 13203 W PALO VERDE DR
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City | LITCHFIELD PARK
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State | AZ
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Zip | 85340-8356
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Country | US
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Telephone | 623-826-7748
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Fax | 623-535-9711
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Authorized Official
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Title or Position | OWNER
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Name | JACKIE PHAN
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Credential |
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Telephone | 623-826-7748
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | Y005332
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License Number State | AZ
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