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General NPI Number Information
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NPI Number | 1518739069
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Entity Type | Individual
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Provider Name | BUNNARITH MAO
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Gender | Male
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Dates
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Enumeration Date | 10/27/2023
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Last Update Date | 10/27/2023
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Provider Practice Location Address
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Address Line | 4870 W DAVIS ST
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City | CONROE
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State | TX
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Zip | 77304-4280
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Country | US
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Telephone | 936-760-3883
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Fax |
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Provider Business Mailing Address
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Address Line | 842 COUNTRY CLUB DR
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City | LA GRANGE
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State | TX
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Zip | 78945-5123
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 73118
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License Number State | TX
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