Provider Demographics
NPI:1578175832
Name:PHAN, TAI TIEN
Entity Type:Individual
Prefix:
First Name:TAI
Middle Name:TIEN
Last Name:PHAN
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 1:1406 E HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-7101
Mailing Address - Country:US
Mailing Address - Phone:956-412-8362
Mailing Address - Fax:
Practice Address - Street 1:701 E RIDGE RD
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1553
Practice Address - Country:US
Practice Address - Phone:956-683-9392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63011183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist