Provider Demographics
NPI:1093053415
Name:TRAN, PHUONG THAO THI
Entity Type:Individual
Prefix:
First Name:PHUONG THAO
Middle Name:THI
Last Name:TRAN
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 1:7018 W WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-2292
Mailing Address - Country:US
Mailing Address - Phone:813-884-5705
Mailing Address - Fax:
Practice Address - Street 1:7018 W WATERS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-2292
Practice Address - Country:US
Practice Address - Phone:813-884-5705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS42205183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist