Healthcare Provider Details

I. General information

NPI: 1558631333
Provider Name (Legal Business Name): PHU TRUNG THAI PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 01/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11290 W BROAD ST
GLEN ALLEN VA
23060-5815
US

IV. Provider business mailing address

11290 W BROAD ST
GLEN ALLEN VA
23060-5815
US

V. Phone/Fax

Practice location:
  • Phone: 804-360-8912
  • Fax: 804-360-8912
Mailing address:
  • Phone: 804-360-8912
  • Fax: 804-360-8912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202206659
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3417
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: