Healthcare Provider Details

I. General information

NPI: 1205863826
Provider Name (Legal Business Name): PHONG X DUONG PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD
DECATUR GA
30033-4004
US

IV. Provider business mailing address

2468 BURNT LEAF LN
DECATUR GA
30033
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax: 404-329-2238
Mailing address:
  • Phone: 404-633-8095
  • Fax: 404-329-2238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number12687
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: