=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588118640
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THANH NGO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2016
-----------------------------------------------------
Last Update Date | 08/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5201 N SHERIDAN RD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-2512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-506-0910
-----------------------------------------------------
Fax | 773-506-0960
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5201 N SHERIDAN RD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-2512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-506-0910
-----------------------------------------------------
Fax | 773-506-0960
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 051299695
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------