Provider Demographics
NPI:1790398774
Name:PHAN, QUANG THIEN
Entity Type:Individual
Prefix:
First Name:QUANG
Middle Name:THIEN
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 1:1811 BELVIDERE RD
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-7221
Mailing Address - Country:US
Mailing Address - Phone:847-244-7550
Mailing Address - Fax:
Practice Address - Street 1:1811 BELVIDERE RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-7221
Practice Address - Country:US
Practice Address - Phone:847-244-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051302650183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist