Basic Information
| Provider Information | |||||||||
| NPI: | 1689702144 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | QUOCBAO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 KANSAS AVE | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209101954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015188514 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1500 FOREST GLEN RD | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209101483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017547126 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P1200X | 16407 | MD | Y | Pharmacy Service Providers | Pharmacist | Pharmacotherapy |
ID Information
| ID | Type | State | Issuer | Description | 16407 | 01 | MD | PHARMACY LICENSE | OTHER | P-500-723-015-866 | 01 | MD | DRIVER'S LICENSE | OTHER |