MEDICARE: MR. BRYAN THANH PHAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	RPH57094	CA
2	1835P1200X	Pharmacotherapy Pharmacist	RPH57094	CA
3	183500000X	Pharmacist	51263	TX

General Provider Information

NPI Number	:	1225051733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRYAN THANH PHAN

Provider Business Mailing Address
First Line	:	6609 W SAM HOUSTON PKWY S STE 98B
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77072-1641
Country	:	US
Telephone Number	:	713-995-8885
Fax Number	:	713-776-9990

Provider Business Practice Location Address
First Line	:	6609 W SAM HOUSTON PKWY S STE 98B
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77072-1641
Country	:	US
Telephone Number	:	713-995-8885
Fax Number	:	713-776-9990

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	02/11/2020

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