Provider Demographics
NPI:1164635934
Name:NGUYEN PHAM, MONGTU THI (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MONGTU
Middle Name:THI
Last Name:NGUYEN PHAM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 S EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6351
Mailing Address - Country:US
Mailing Address - Phone:208-706-1520
Mailing Address - Fax:
Practice Address - Street 1:520 S. EAGLE ROAD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-706-1523
Practice Address - Fax:208-706-1543
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8912183500000X
IDP5321183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist