Provider Demographics
NPI:1790906220
Name:PHAM, LOAN NGOC
Entity Type:Individual
Prefix:
First Name:LOAN
Middle Name:NGOC
Last Name:PHAM
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 1:43332 VESTALS PLACE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176
Mailing Address - Country:US
Mailing Address - Phone:571-333-3979
Mailing Address - Fax:
Practice Address - Street 1:1079 EDWARDS FERRY RD NE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176
Practice Address - Country:US
Practice Address - Phone:703-554-6021
Practice Address - Fax:703-554-6024
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011441183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist