Provider Demographics
NPI:1699080804
Name:PHAM, MARIE THI (PHARM D)
Entity type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:THI
Last Name:PHAM
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4197
Mailing Address - Country:US
Mailing Address - Phone:985-645-0488
Mailing Address - Fax:985-645-0416
Practice Address - Street 1:100 N MILITARY RD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4197
Practice Address - Country:US
Practice Address - Phone:985-645-0488
Practice Address - Fax:985-645-0416
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16988183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist