Provider Demographics
NPI:1235444373
Name:VU, PHONG THANH
Entity Type:Individual
Prefix:MR
First Name:PHONG
Middle Name:THANH
Last Name:VU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 PASS RD
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-2111
Mailing Address - Country:US
Mailing Address - Phone:228-388-3458
Mailing Address - Fax:
Practice Address - Street 1:2405 PASS RD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2111
Practice Address - Country:US
Practice Address - Phone:228-388-3458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS010401183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist