Healthcare Provider Details

I. General information

NPI: 1316011802
Provider Name (Legal Business Name): THY PHAM PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 W YOSEMITE AVE
MANTECA CA
95337-5130
US

IV. Provider business mailing address

PO BOX 581532
ELK GROVE CA
95758-0026
US

V. Phone/Fax

Practice location:
  • Phone: 209-825-3616
  • Fax:
Mailing address:
  • Phone: 916-719-8594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number50290
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: