Provider Demographics
NPI:1518317908
Name:PHAM, KIM D (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:D
Last Name:PHAM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MRS
Other - First Name:KIM
Other - Middle Name:PHAM
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:140 GARRETT RD
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-3106
Mailing Address - Country:US
Mailing Address - Phone:610-352-2477
Mailing Address - Fax:610-352-3911
Practice Address - Street 1:140 GARRETT RD
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-3106
Practice Address - Country:US
Practice Address - Phone:610-352-2477
Practice Address - Fax:610-352-3911
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP033704L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032268190001Medicaid