=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164709622
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THUY T HOANG PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2011
-----------------------------------------------------
Last Update Date | 11/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 W CENTRAL AVE
-----------------------------------------------------
City | PETAL
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39465-2313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-554-3236
-----------------------------------------------------
Fax | 601-554-9781
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 TWIN LAKE XING
-----------------------------------------------------
City | HATTIESBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39401-0700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-447-1111
-----------------------------------------------------
Fax | 601-554-9781
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | E-010022
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------