Healthcare Provider Details

I. General information

NPI: 1194414243
Provider Name (Legal Business Name): THU NGUYEN TRANG PHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2023
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PICACHO RD
WINTERHAVEN CA
92283-9605
US

IV. Provider business mailing address

7196 E 25TH PL
YUMA AZ
85365-7879
US

V. Phone/Fax

Practice location:
  • Phone: 760-572-4100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS026141
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: