Provider Demographics
NPI:1750611083
Name:TRA, PHUONG-THANH (RPH)
Entity type:Individual
Prefix:
First Name:PHUONG-THANH
Middle Name:
Last Name:TRA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 172ND PL SE
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-9188
Mailing Address - Country:US
Mailing Address - Phone:425-742-3960
Mailing Address - Fax:425-742-3960
Practice Address - Street 1:13110 BOTHELL-EVERETT HIGHWAY.
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208
Practice Address - Country:US
Practice Address - Phone:425-379-7274
Practice Address - Fax:425-385-8775
Is Sole Proprietor?:No
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00039631183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist