MEDICARE: MR. BRANDON V THACH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS39614	FL
2	183500000X	Pharmacist	PH23820	MA

General Provider Information

NPI Number	:	1013254176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRANDON V THACH

Provider Business Mailing Address
First Line	:	160 MARINER BLVD
Second Line	:	160 MARINER BLVD
City	:	SPRING HILL
State	:	FL
Zip	:	34609-5689
Country	:	US
Telephone Number	:	352-688-2305
Fax Number	:	352-666-2122

Provider Business Practice Location Address
First Line	:	160 MARINER BLVD
Second Line	:	160 MARINER BLVD
City	:	SPRING HILL
State	:	FL
Zip	:	34609-5689
Country	:	US
Telephone Number	:	352-688-2305
Fax Number	:	352-666-2122

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2013
Last Update Date	:	01/09/2013

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