Provider Demographics
NPI:1265642656
Name:NGUYEN, PHUONG THAO THI
Entity Type:Individual
Prefix:
First Name:PHUONG THAO
Middle Name:THI
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PHUONG THAO
Other - Middle Name:THI
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3503 UNIVERSITY PARK LN
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-6590
Mailing Address - Country:US
Mailing Address - Phone:972-650-0979
Mailing Address - Fax:214-630-0473
Practice Address - Street 1:4828 READING ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-6705
Practice Address - Country:US
Practice Address - Phone:214-630-0333
Practice Address - Fax:214-630-0473
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37311183500000X
OK12509183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist