Provider Demographics
NPI:1063748507
Name:PHUNG, TRUONG-VINH
Entity type:Individual
Prefix:
First Name:TRUONG-VINH
Middle Name:
Last Name:PHUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 RESERVOIR ST
Mailing Address - Street 2:
Mailing Address - City:NORTON
Mailing Address - State:MA
Mailing Address - Zip Code:02766-1507
Mailing Address - Country:US
Mailing Address - Phone:508-802-7446
Mailing Address - Fax:
Practice Address - Street 1:1050 W PERIMETER RD
Practice Address - Street 2:STE. E1-24
Practice Address - City:ANDREWS AIR FORCE BASE
Practice Address - State:MD
Practice Address - Zip Code:20762-6601
Practice Address - Country:US
Practice Address - Phone:508-802-7446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-18
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA099819390200000X
MAPH233178183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program