Healthcare Provider Details

I. General information

NPI: 1689458184
Provider Name (Legal Business Name): TINA DIEM TRAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6731 WOODLAND AVE
PHILADELPHIA PA
19142-1602
US

IV. Provider business mailing address

6320 GREENWAY AVE
PHILADELPHIA PA
19142-2018
US

V. Phone/Fax

Practice location:
  • Phone: 215-724-9677
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP457771
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: