Provider Demographics
NPI:1689606931
Name:PHAM, KHANH BAO (CDE, RPH)
Entity Type:Individual
Prefix:
First Name:KHANH
Middle Name:BAO
Last Name:PHAM
Suffix:
Gender:F
Credentials:CDE, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:1397 S LOOP RD
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-4729
Practice Address - Country:US
Practice Address - Phone:775-751-7100
Practice Address - Fax:775-751-7824
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2023-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10686183500000X, 1835P1200X, 1835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835N1003XPharmacy Service ProvidersPharmacistNutrition Support
No183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy