Provider Demographics
NPI:1871970889
Name:PHUNG, MARY-THANH
Entity type:Individual
Prefix:
First Name:MARY-THANH
Middle Name:
Last Name:PHUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 RANCH DR
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-5100
Mailing Address - Country:US
Mailing Address - Phone:408-934-0304
Mailing Address - Fax:
Practice Address - Street 1:301 RANCH DR
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-5100
Practice Address - Country:US
Practice Address - Phone:408-934-0304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72348183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist