Provider Demographics
NPI:1366116311
Name:PHAM, KEVIN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3085 YUKON DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:TN
Mailing Address - Zip Code:38002-4902
Mailing Address - Country:US
Mailing Address - Phone:901-504-0625
Mailing Address - Fax:
Practice Address - Street 1:6310 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4734
Practice Address - Country:US
Practice Address - Phone:901-680-1907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN45346183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist