Provider Demographics
NPI:1497564066
Name:PHAN, TIMOTHY
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11710 DALHOUSIE DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-3315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3950 W GRAND PKWY N
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-2398
Practice Address - Country:US
Practice Address - Phone:281-574-5407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75235183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist