=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508227505
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAM MINH TRAN PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2016
-----------------------------------------------------
Last Update Date | 12/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 880 HIGHWAY 85 S
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-817-4787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3865 NIELSEN CT
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30021-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-862-6034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | E13238
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PS51142
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH028050
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------