Basic Information
| Provider Information | |||||||||
| NPI: | 1376993915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | PHU | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 BUTTONWOOD ST APT 1 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021251204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8572441075 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 850 HARRISON AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021184001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176388000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2016 | ||||||||
| LastUpdateDate: | 06/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PH235227 | MA | Y | Pharmacy Service Providers | Pharmacist | 183500000X | 71942 | CA | N | Pharmacy Service Providers | Pharmacist |
No ID Information.