Provider Demographics
NPI:1659877520
Name:PHAN, TUYEN QUANG
Entity Type:Individual
Prefix:
First Name:TUYEN
Middle Name:QUANG
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 1:5134 LIVERMORE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-3015
Mailing Address - Country:US
Mailing Address - Phone:702-267-8967
Mailing Address - Fax:
Practice Address - Street 1:454 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NC
Practice Address - Zip Code:28675-9606
Practice Address - Country:US
Practice Address - Phone:336-372-2101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-01
Last Update Date:2018-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26808183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist