Provider Demographics
NPI:1972199180
Name:PHAM, VAN KHANH
Entity Type:Individual
Prefix:MRS
First Name:VAN
Middle Name:KHANH
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 1:2324 US HWY 17
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324
Mailing Address - Country:US
Mailing Address - Phone:912-756-2531
Mailing Address - Fax:912-756-2558
Practice Address - Street 1:2324 US HWY 17
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324
Practice Address - Country:US
Practice Address - Phone:912-756-2531
Practice Address - Fax:912-756-2558
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-12
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHTC0007523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy