Provider Demographics
NPI:1659962116
Name:LE, PHUONG
Entity Type:Individual
Prefix:
First Name:PHUONG
Middle Name:
Last Name:LE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-2106
Mailing Address - Country:US
Mailing Address - Phone:770-267-8412
Mailing Address - Fax:
Practice Address - Street 1:312 S BROAD ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-2106
Practice Address - Country:US
Practice Address - Phone:770-267-8412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH031071183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist