Healthcare Provider Details

I. General information

NPI: 1922833102
Provider Name (Legal Business Name): NGAN PHAM PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-4353
  • Fax:
Mailing address:
  • Phone: 208-381-4353
  • Fax: 208-381-4355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberI75629
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: