Basic Information
Provider Information
NPI: 1003142753
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PHUONG
FirstName: LINH
MiddleName: K
NamePrefix:  
NameSuffix:  
Credential: RPH
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 18420 N 19TH AVE
Address2:  
City: PHOENIX
State: AZ
PostalCode: 850231361
CountryCode: US
TelephoneNumber: 6029936610
FaxNumber:  
Practice Location
Address1: 18420 N 19TH AVE
Address2:  
City: PHOENIX
State: AZ
PostalCode: 850231361
CountryCode: US
TelephoneNumber: 6029936610
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/29/2009
LastUpdateDate: 07/17/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X15804AZY Pharmacy Service ProvidersPharmacist 

No ID Information.


Home