Provider Demographics
NPI:1003284241
Name:PHAM, PENANG (PHARM D)
Entity Type:Individual
Prefix:
First Name:PENANG
Middle Name:
Last Name:PHAM
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 1:2610 E NEES AVE APT 279
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-6023
Mailing Address - Country:US
Mailing Address - Phone:714-722-5969
Mailing Address - Fax:
Practice Address - Street 1:6074 N 1ST ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5405
Practice Address - Country:US
Practice Address - Phone:559-431-5231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73420183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist