Provider Demographics
NPI:1417012840
Name:VIETNAM PHARMACY
Entity Type:Organization
Organization Name:VIETNAM PHARMACY
Other - Org Name:VIETNAM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:THUY
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-520-0205
Mailing Address - Street 1:2621 MILAM STREET
Mailing Address - Street 2:SUITE C
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77006-2300
Mailing Address - Country:US
Mailing Address - Phone:713-520-0205
Mailing Address - Fax:713-520-9714
Practice Address - Street 1:2621 MILAM ST STE C
Practice Address - Street 2:SUITE C
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77006-2300
Practice Address - Country:US
Practice Address - Phone:713-520-0205
Practice Address - Fax:713-520-9714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX158863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1439418Medicaid
4578564OtherOTHER ID NUMBER-COMMERCIAL NUMBER
4578564OtherOTHER ID NUMBER