Provider Demographics
NPI:1770819401
Name:PHAM, BAO H (RPH)
Entity Type:Individual
Prefix:
First Name:BAO
Middle Name:H
Last Name:PHAM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4121 HARWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-4021
Mailing Address - Country:US
Mailing Address - Phone:817-571-6995
Mailing Address - Fax:817-571-8583
Practice Address - Street 1:4121 HARWOOD RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-4021
Practice Address - Country:US
Practice Address - Phone:817-571-6995
Practice Address - Fax:817-571-8583
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-31
Last Update Date:2009-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist