Provider Demographics
NPI:1083997290
Name:PHAM, KIM PHUONG
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:PHUONG
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 1:216 BUCKTAIL DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-6130
Mailing Address - Country:US
Mailing Address - Phone:302-449-0456
Mailing Address - Fax:
Practice Address - Street 1:216 BUCKTAIL DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-6130
Practice Address - Country:US
Practice Address - Phone:302-449-0456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0003692183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist