=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811597040
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THAO N KHAMNOUANE PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2020
-----------------------------------------------------
Last Update Date | 10/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12000 MCCREE RD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75238-3275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-461-8777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6303 CREEK BLUFF CT
-----------------------------------------------------
City | SACHSE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75048-5658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 48801
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------