MEDICARE: MYMIE PHAM

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	183500000X	Pharmacist	PH26479	MA

General Provider Information

NPI Number	:	1356939813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYMIE PHAM

Provider Business Mailing Address
First Line	:	151 TREMONT ST APT 25B
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02111-1123
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	451 WASHINGTON ST
Second Line	:
City	:	DORCHESTER
State	:	MA
Zip	:	02124-1138
Country	:	US
Telephone Number	:	617-740-0611
Fax Number	:

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

Provider Enumeration Date	:	01/08/2021
Last Update Date	:	01/08/2021

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Directions to “ MYMIE PHAM ” Practice Location

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