Provider Demographics
NPI:1689957789
Name:PHAN, TOMMY
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:
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 1:3332 KIMBERLY LN
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-7041
Mailing Address - Country:US
Mailing Address - Phone:504-355-7501
Mailing Address - Fax:
Practice Address - Street 1:6244 LAKE WORTH BLVD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3705
Practice Address - Country:US
Practice Address - Phone:817-238-0385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-25
Last Update Date:2011-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX49371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist