Provider Demographics
NPI:1609441351
Name:PHAM, KEN LUONG
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:LUONG
Last Name:PHAM
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 1:516 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-2811
Mailing Address - Country:US
Mailing Address - Phone:972-762-4115
Mailing Address - Fax:
Practice Address - Street 1:412 E COLLEGE WAY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5516
Practice Address - Country:US
Practice Address - Phone:360-424-7958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62183183500000X
WAPH60844394183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist