Provider Demographics
NPI:1083214563
Name:PHAM, TRACEY
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:PHAM
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 1:9426 LIMESTONE RANCH LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-1763
Mailing Address - Country:US
Mailing Address - Phone:281-633-6409
Mailing Address - Fax:
Practice Address - Street 1:14215 FM 2100 RD
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:TX
Practice Address - Zip Code:77532-9152
Practice Address - Country:US
Practice Address - Phone:281-328-3529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65590183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist