Provider Demographics
NPI:1790097707
Name:PHAN, THANHVAN T
Entity Type:Individual
Prefix:MRS
First Name:THANHVAN
Middle Name:T
Last Name:PHAN
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 1:38 MARGARET RD
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-3997
Mailing Address - Country:US
Mailing Address - Phone:617-669-6124
Mailing Address - Fax:
Practice Address - Street 1:47 MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-4505
Practice Address - Country:US
Practice Address - Phone:781-961-1246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-07
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH24713183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist