Provider Demographics
NPI:1316221104
Name:DUONG, PHONG
Entity Type:Individual
Prefix:
First Name:PHONG
Middle Name:
Last Name:DUONG
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 1:812 NW 18TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-1508
Mailing Address - Country:US
Mailing Address - Phone:405-512-9263
Mailing Address - Fax:
Practice Address - Street 1:1201 NW 12TH ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73170-1220
Practice Address - Country:US
Practice Address - Phone:405-799-2244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14792183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist