Provider Demographics
NPI:1689149684
Name:HOANG, PHUONG MAI (PHARMD)
Entity Type:Individual
Prefix:
First Name:PHUONG
Middle Name:MAI
Last Name:HOANG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 NACO RD
Mailing Address - Street 2:
Mailing Address - City:BISBEE
Mailing Address - State:AZ
Mailing Address - Zip Code:85603-9655
Mailing Address - Country:US
Mailing Address - Phone:703-340-9101
Mailing Address - Fax:
Practice Address - Street 1:101 NACO RD
Practice Address - Street 2:
Practice Address - City:BISBEE
Practice Address - State:AZ
Practice Address - Zip Code:85603-9655
Practice Address - Country:US
Practice Address - Phone:703-340-9101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-05
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP452612183500000X
AZS023769183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS023769OtherARIZONA STATE BOARD OF PHARMACY
PARP452612OtherSTATE BOARD OF PHARMACY