Provider Demographics
NPI:1053172213
Name:PHAM, CHRISTOPHER
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2120
Mailing Address - Country:US
Mailing Address - Phone:903-592-8115
Mailing Address - Fax:
Practice Address - Street 1:1301 CLINIC DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2120
Practice Address - Country:US
Practice Address - Phone:903-592-8115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX734411835N0905X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835N0905XPharmacy Service ProvidersPharmacistNuclear