MEDICARE: JONATHAN PHAM PHARMD

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	57768	TX

General Provider Information

NPI Number	:	1265031041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN PHAM PHARMD

Provider Business Mailing Address
First Line	:	2303 BOONVILLE RD
Second Line	:
City	:	BRYAN
State	:	TX
Zip	:	77808-2232
Country	:	US
Telephone Number	:	979-774-8377
Fax Number	:	979-774-8362

Provider Business Practice Location Address
First Line	:	2303 BOONVILLE RD
Second Line	:
City	:	BRYAN
State	:	TX
Zip	:	77808-2232
Country	:	US
Telephone Number	:	979-774-8377
Fax Number	:	979-774-8362

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

Provider Enumeration Date	:	10/22/2020
Last Update Date	:	10/22/2020

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