Provider Demographics
NPI:1154880961
Name:PHAM, THAO THANH (RPH)
Entity type:Individual
Prefix:
First Name:THAO
Middle Name:THANH
Last Name:PHAM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:THANH-THAO
Other - Middle Name:THI
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:14444 COURSEY BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-1319
Mailing Address - Country:US
Mailing Address - Phone:225-753-1499
Mailing Address - Fax:
Practice Address - Street 1:14444 COURSEY BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-1319
Practice Address - Country:US
Practice Address - Phone:225-753-1499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022696183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist