Provider Demographics
NPI:1669077665
Name:PHAM, DONNA DUYEN
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:DUYEN
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 1:4825 EDDLEMAN DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-9122
Mailing Address - Country:US
Mailing Address - Phone:817-781-5937
Mailing Address - Fax:
Practice Address - Street 1:3220 DENTON HWY
Practice Address - Street 2:
Practice Address - City:HALTOM CITY
Practice Address - State:TX
Practice Address - Zip Code:76117-3717
Practice Address - Country:US
Practice Address - Phone:817-831-4488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39639183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1760586556Other1760586556