Provider Demographics
NPI:1023575735
Name:PHAN, TIMOTHY (PHARM D)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:TUE
Other - Middle Name:
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1425 N HACIENDA BLVD
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-1133
Mailing Address - Country:US
Mailing Address - Phone:626-251-1906
Mailing Address - Fax:
Practice Address - Street 1:1425 N HACIENDA BLVD
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-1133
Practice Address - Country:US
Practice Address - Phone:626-251-1906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80237183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist