Provider Demographics
NPI:1568211894
Name:PHAM, RYAN AARON
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:AARON
Last Name:PHAM
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 1:4 BLUE HERON DR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-3381
Mailing Address - Country:US
Mailing Address - Phone:805-722-6411
Mailing Address - Fax:
Practice Address - Street 1:116 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03867-4352
Practice Address - Country:US
Practice Address - Phone:603-332-5540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHPHCY-02111183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist