Healthcare Provider Details

I. General information

NPI: 1770022717
Provider Name (Legal Business Name): THY PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2212 FELLOWSHIP RD
TUCKER GA
30084-4609
US

IV. Provider business mailing address

2215 CHESHIRE BRIDGE RD NE STE D
ATLANTA GA
30324-4234
US

V. Phone/Fax

Practice location:
  • Phone: 404-590-3785
  • Fax: 678-883-0856
Mailing address:
  • Phone: 404-590-3785
  • Fax: 678-883-0856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH022317
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: