MEDICARE: PHUONG TUAN 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	PS49101	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PS49101	OTHER	FL	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1366085946
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHUONG TUAN PHAM

Provider Business Mailing Address
First Line	:	4444 W VINE ST
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34746-5315
Country	:	US
Telephone Number	:	407-397-1002
Fax Number	:	407-397-1249

Provider Business Practice Location Address
First Line	:	1926 CROSSHAIR CIR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32837-7402
Country	:	US
Telephone Number	:	407-456-4170
Fax Number	:

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

Provider Enumeration Date	:	10/25/2019
Last Update Date	:	10/25/2019

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Directions to “ PHUONG TUAN PHAM ” Practice Location

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