Provider Demographics
NPI:1053942292
Name:TAM, JONATHAN (PHARM D)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:TAM
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21700 KINGSLAND BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-2546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21700 KINGSLAND BLVD STE 105
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-2546
Practice Address - Country:US
Practice Address - Phone:281-829-6497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63458183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist