Provider Demographics
NPI:1780456921
Name:THAO, MAI ONG MARY
Entity type:Individual
Prefix:
First Name:MAI ONG
Middle Name:MARY
Last Name:THAO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12155 BRILLIANT WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95742-8266
Mailing Address - Country:US
Mailing Address - Phone:530-828-6664
Mailing Address - Fax:
Practice Address - Street 1:10881 OLSON DR
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-5646
Practice Address - Country:US
Practice Address - Phone:916-503-2513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88796183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist