Provider Demographics
NPI:1144662115
Name:PHAM, TRAVIS THAI VINH (PHARMD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:THAI VINH
Last Name:PHAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 UPLAND DR.
Mailing Address - Street 2:PO BOX # 6660
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1321 UPLAND DR
Practice Address - Street 2:#6660
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77043-4718
Practice Address - Country:US
Practice Address - Phone:559-470-6969
Practice Address - Fax:559-470-6970
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-19
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68590183500000X
NY057528183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist