Provider Demographics
NPI:1902400435
Name:PHAM, ANHTHAO
Entity Type:Individual
Prefix:
First Name:ANHTHAO
Middle Name:
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 1:7501 HUNTSMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22153-1649
Mailing Address - Country:US
Mailing Address - Phone:703-866-2336
Mailing Address - Fax:844-411-6539
Practice Address - Street 1:7501 HUNTSMAN BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22153-1649
Practice Address - Country:US
Practice Address - Phone:703-866-2336
Practice Address - Fax:844-411-6539
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202205054183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist