Provider Demographics
NPI:1649814492
Name:PHAM, NGOC PHUNG THI
Entity type:Individual
Prefix:
First Name:NGOC PHUNG
Middle Name:THI
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 1:500 S 99TH AVE
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-9700
Mailing Address - Country:US
Mailing Address - Phone:800-576-4377
Mailing Address - Fax:
Practice Address - Street 1:87 E WILLIAMS FIELD RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-5202
Practice Address - Country:US
Practice Address - Phone:480-726-3813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS024315183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist