Basic Information
| Provider Information | |||||||||
| NPI: | 1144662115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | THAI VINH | ||||||||
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| Credential: | PHARM.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1321 UPLAND DR. | ||||||||
| Address2: | PO BOX # 6660 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77043 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1321 UPLAND DR | ||||||||
| Address2: | #6660 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770434718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594706969 | ||||||||
| FaxNumber: | 5594706970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2013 | ||||||||
| LastUpdateDate: | 02/03/2016 | ||||||||
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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 | 68590 | CA | Y | Pharmacy Service Providers | Pharmacist | 183500000X | 057528 | NY | N | Pharmacy Service Providers | Pharmacist |
No ID Information.