Provider Demographics
NPI:1073334280
Name:LUONG, THI MINH TAM
Entity type:Individual
Prefix:
First Name:THI MINH TAM
Middle Name:
Last Name:LUONG
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 1:7351 MONETS GDN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78218-3121
Mailing Address - Country:US
Mailing Address - Phone:774-641-1605
Mailing Address - Fax:
Practice Address - Street 1:1915 BROADWAY ST STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1133
Practice Address - Country:US
Practice Address - Phone:210-806-8741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH241712183500000X
TX74506183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist