Provider Demographics
NPI:1982571741
Name:PHAM, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
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 1:737 MANDALAY BAY DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-4199
Mailing Address - Country:US
Mailing Address - Phone:972-693-1735
Mailing Address - Fax:
Practice Address - Street 1:1177 US HIGHWAY 380
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-6075
Practice Address - Country:US
Practice Address - Phone:469-296-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-17
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX76519183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist