Provider Demographics
NPI:1013512656
Name:PHAM, JENNY (PHARMD)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:686 GLADES RD
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6414
Mailing Address - Country:US
Mailing Address - Phone:561-395-6130
Mailing Address - Fax:
Practice Address - Street 1:686 GLADES RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6414
Practice Address - Country:US
Practice Address - Phone:561-395-6130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL54015183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist