Healthcare Provider Details

I. General information

NPI: 1053636456
Provider Name (Legal Business Name): NICOLE T PHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E PIONEER PKWY
ARLINGTON TX
76010-5243
US

IV. Provider business mailing address

3806 PARK MANOR CT
ARLINGTON TX
76017-1593
US

V. Phone/Fax

Practice location:
  • Phone: 817-860-9510
  • Fax:
Mailing address:
  • Phone: 817-412-0007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number42139
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: