MEDICARE: AIDIEM 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	RPH023400	GA

General Provider Information

NPI Number	:	1760778013
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AIDIEM PHAM

Provider Business Mailing Address
First Line	:	2535 DALLAS HWY SW
Second Line	:	T-1165
City	:	MARIETTA
State	:	GA
Zip	:	30064-2661
Country	:	US
Telephone Number	:	770-427-4136
Fax Number	:

Provider Business Practice Location Address
First Line	:	2535 DALLAS HWY SW
Second Line	:	T-1165
City	:	MARIETTA
State	:	GA
Zip	:	30064-2661
Country	:	US
Telephone Number	:	770-427-4136
Fax Number	:

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

Provider Enumeration Date	:	06/24/2011
Last Update Date	:	06/24/2011

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Directions to “ AIDIEM PHAM ” Practice Location

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