Provider Demographics
NPI:1922608793
Name:PHAM, TRACY TRAM
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:TRAM
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 1:5538 DORCHESTER LN
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75040-4493
Mailing Address - Country:US
Mailing Address - Phone:214-718-4156
Mailing Address - Fax:
Practice Address - Street 1:700 E ENNIS AVE
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-4209
Practice Address - Country:US
Practice Address - Phone:972-875-9636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX56329183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist