Provider Demographics
NPI:1609593250
Name:PHAN, NICHOLAS (RPH)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 CHRIS KELLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:HUTTO
Mailing Address - State:TX
Mailing Address - Zip Code:78634-5088
Mailing Address - Country:US
Mailing Address - Phone:512-846-1003
Mailing Address - Fax:512-846-1336
Practice Address - Street 1:301 CHRIS KELLEY BLVD
Practice Address - Street 2:
Practice Address - City:HUTTO
Practice Address - State:TX
Practice Address - Zip Code:78634-5088
Practice Address - Country:US
Practice Address - Phone:512-846-1003
Practice Address - Fax:512-846-1336
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61286183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist