Provider Demographics
NPI:1164807350
Name:PHAM, THUC TRAN VAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:THUC
Middle Name:TRAN VAN
Last Name:PHAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:TODD
Other - Middle Name:TRAN VAN
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:90 VANDENBERG DR, BLDG 1900
Mailing Address - Street 2:66 MDS (AFMC)
Mailing Address - City:HANSCOM AFB
Mailing Address - State:MA
Mailing Address - Zip Code:01731-2104
Mailing Address - Country:US
Mailing Address - Phone:781-225-6789
Mailing Address - Fax:781-225-2576
Practice Address - Street 1:90 VANDENBERG DR BLDG 1900
Practice Address - Street 2:66 MDS (AFMC)
Practice Address - City:HANSCOM AFB
Practice Address - State:MA
Practice Address - Zip Code:01731-2104
Practice Address - Country:US
Practice Address - Phone:781-225-6789
Practice Address - Fax:781-225-2576
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist