Provider Demographics
NPI:1154174639
Name:LE, PHUONG VIET TUAN (PHARMD)
Entity type:Individual
Prefix:
First Name:PHUONG
Middle Name:VIET TUAN
Last Name:LE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 E LLANO ESTACADO BLVD APT M
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4176
Mailing Address - Country:US
Mailing Address - Phone:210-639-5578
Mailing Address - Fax:
Practice Address - Street 1:700 E 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-3703
Practice Address - Country:US
Practice Address - Phone:575-762-3851
Practice Address - Fax:575-762-5698
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73796183500000X
NMRP00010096183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist