MEDICARE: THAO LIEU

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	61389	TX

General Provider Information

NPI Number	:	1104429034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THAO LIEU

Provider Business Mailing Address
First Line	:	1800 N HALL ST APT 229
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75204-4130
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8520 CAMP BOWIE WEST BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-6203
Country	:	US
Telephone Number	:	817-560-0130
Fax Number	:

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

Provider Enumeration Date	:	11/21/2020
Last Update Date	:	11/21/2020

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Directions to “ THAO LIEU ” Practice Location

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