1093812927 NPI number — TAN THAI INC

Table of content: (NPI 1093812927)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093812927 NPI number — TAN THAI INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAN THAI INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OLD VILLAGE PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093812927
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
978 GALLOWAY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALLOWAY
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43119-8293
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-853-3498
Provider Business Mailing Address Fax Number:
614-853-4022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
978 GALLOWAY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALLOWAY
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43119-8293
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-853-3498
Provider Business Practice Location Address Fax Number:
614-853-4022
Provider Enumeration Date:
09/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
THAI
Authorized Official First Name:
TAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT, OWNER, PIC, AO
Authorized Official Telephone Number:
614-853-3498

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 021330450 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2078707 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2332738 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".