Basic Information
| Provider Information | |||||||||
| NPI: | 1720687502 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | THIEN AN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3801 VITRUVIAN WAY APT 420 | ||||||||
| Address2: | |||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8329291008 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3701 IRA E WOODS AVE | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760514213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172512428 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2020 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 67605 | TX | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.