Provider Demographics
NPI:1215256573
Name:TRAN, THANH PHUOC
Entity type:Individual
Prefix:
First Name:THANH
Middle Name:PHUOC
Last Name:TRAN
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 1:1212 SUMMIT AVENUE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307
Mailing Address - Country:US
Mailing Address - Phone:201-876-0107
Mailing Address - Fax:201-876-0142
Practice Address - Street 1:1212 SUMMIT AVE.
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307
Practice Address - Country:US
Practice Address - Phone:201-876-0107
Practice Address - Fax:201-876-0142
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03060500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist