Provider Demographics
NPI:1508533894
Name:PHAN, DIEM HONG (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:DIEM
Middle Name:HONG
Last Name:PHAN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10122 FOURNIER AVE
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-5458
Mailing Address - Country:US
Mailing Address - Phone:228-243-6767
Mailing Address - Fax:
Practice Address - Street 1:10122 FOURNIER AVE
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-5458
Practice Address - Country:US
Practice Address - Phone:228-243-6767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-100327183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist