Healthcare Provider Details

I. General information

NPI: 1982204020
Provider Name (Legal Business Name): HUNG PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 NEW BOSTON RD
TEXARKANA TX
75501-2819
US

IV. Provider business mailing address

3327 CANYON RD
GRAND PRAIRIE TX
75052-7886
US

V. Phone/Fax

Practice location:
  • Phone: 903-831-3023
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number63696
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: