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General NPI Number Information
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NPI Number | 1871069310
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Entity Type | Individual
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Provider Name | EDWIN MA THAO
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Gender | Male
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Dates
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Enumeration Date | 10/23/2018
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Last Update Date | 09/12/2022
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Provider Practice Location Address
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Address Line | 11850 BLACKFOOT ST NW STE 190
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City | COON RAPIDS
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State | MN
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Zip | 55433-2583
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Country | US
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Telephone | 763-236-7111
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Fax |
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Provider Business Mailing Address
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Address Line | 18212 79TH PL N
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City | MAPLE GROVE
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State | MN
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Zip | 55311-1911
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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 | 125332
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 79678
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License Number State | CA
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