Provider Demographics
NPI:1033473962
Name:LIEU, PHONG CHAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:PHONG
Middle Name:CHAN
Last Name:LIEU
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 1:4363 PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-2117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4363 PACIFIC ST
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-2117
Practice Address - Country:US
Practice Address - Phone:916-632-7560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 60473776183500000X
CA76315183500000X
CA106241835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric
No183500000XPharmacy Service ProvidersPharmacist