Provider Demographics
NPI:1023614575
Name:PHAN, PHI THUONG (PHARM D)
Entity type:Individual
Prefix:MR
First Name:PHI
Middle Name:THUONG
Last Name:PHAN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 MATLOCK RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3855
Mailing Address - Country:US
Mailing Address - Phone:817-453-0267
Mailing Address - Fax:817-453-0273
Practice Address - Street 1:2200 MATLOCK RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3855
Practice Address - Country:US
Practice Address - Phone:817-453-0267
Practice Address - Fax:817-453-0273
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX54344183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist