Provider Demographics
NPI:1720687502
Name:PHAM, PATRICK THIEN AN
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:THIEN AN
Last Name:PHAM
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 1:3801 VITRUVIAN WAY APT 420
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3368
Mailing Address - Country:US
Mailing Address - Phone:832-929-1008
Mailing Address - Fax:
Practice Address - Street 1:3701 IRA E WOODS AVE
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-4213
Practice Address - Country:US
Practice Address - Phone:817-251-2428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67605183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist