Provider Demographics
NPI:1427463546
Name:PHAM, PHONG (RPH)
Entity type:Individual
Prefix:
First Name:PHONG
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14200 W INDIAN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-9248
Mailing Address - Country:US
Mailing Address - Phone:623-935-7578
Mailing Address - Fax:623-935-7581
Practice Address - Street 1:14200 W INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-9248
Practice Address - Country:US
Practice Address - Phone:623-935-7578
Practice Address - Fax:623-935-7581
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS013083183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist