Healthcare Provider Details

I. General information

NPI: 1912817750
Provider Name (Legal Business Name): TIMOTHY PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3306 N UNIVERSITY DR
SUNRISE FL
33351-6773
US

IV. Provider business mailing address

1240 S PINE ISLAND RD APT 222
PLANTATION FL
33324-4493
US

V. Phone/Fax

Practice location:
  • Phone: 954-749-5781
  • Fax:
Mailing address:
  • Phone: 407-802-8367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPS71436
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: