Provider Demographics
NPI:1053621805
Name:PHAM, MY QUANG THI (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MY QUANG
Middle Name:THI
Last Name:PHAM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 WEST GOVERNMENT STREET, APT. F 34
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042
Mailing Address - Country:US
Mailing Address - Phone:770-289-3515
Mailing Address - Fax:
Practice Address - Street 1:219 N WOODLAND DR
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-3307
Practice Address - Country:US
Practice Address - Phone:601-469-3393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS010791183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist