Provider Demographics
NPI:1790455814
Name:LE, ANH THI PHUONG
Entity Type:Individual
Prefix:
First Name:ANH
Middle Name:THI PHUONG
Last Name:LE
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 1:2301 ACADEMIC PL SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4163
Mailing Address - Country:US
Mailing Address - Phone:505-652-8588
Mailing Address - Fax:
Practice Address - Street 1:901 UNSER BLVD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-8712
Practice Address - Country:US
Practice Address - Phone:505-962-9239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00009563333600000X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No333600000XSuppliersPharmacy