Provider Demographics
NPI:1639473747
Name:VAN, TUNG MINH (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:TUNG
Middle Name:MINH
Last Name:VAN
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6232 SHACKELFORD TER
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312-1724
Mailing Address - Country:US
Mailing Address - Phone:703-870-9768
Mailing Address - Fax:
Practice Address - Street 1:36028 DARNALL LOOP
Practice Address - Street 2:
Practice Address - City:FORTHOOD
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-288-8801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202209792183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist