Provider Demographics
NPI:1194306530
Name:PHAN, THU THANH
Entity type:Individual
Prefix:
First Name:THU
Middle Name:THANH
Last Name:PHAN
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 1:14933 LIPTON LN
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-7957
Mailing Address - Country:US
Mailing Address - Phone:512-699-8271
Mailing Address - Fax:
Practice Address - Street 1:1700 E PALM VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-4677
Practice Address - Country:US
Practice Address - Phone:512-255-0617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-17
Last Update Date:2021-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100821183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician