Provider Demographics
NPI:1689279556
Name:VUONG, PHUONG S
Entity Type:Individual
Prefix:
First Name:PHUONG
Middle Name:S
Last Name:VUONG
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 1:12672 SEATON CIR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-0457
Mailing Address - Country:US
Mailing Address - Phone:214-717-9543
Mailing Address - Fax:972-624-0643
Practice Address - Street 1:5300 S COLONY BLVD
Practice Address - Street 2:
Practice Address - City:THE COLONY
Practice Address - State:TX
Practice Address - Zip Code:75056-7331
Practice Address - Country:US
Practice Address - Phone:972-624-0605
Practice Address - Fax:972-624-0643
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38833183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX444761962Medicaid