Provider Demographics
NPI:1043680333
Name:PHAN, ANDY
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 N. WESTERN AVE.
Mailing Address - Street 2:
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67901
Mailing Address - Country:US
Mailing Address - Phone:620-417-7230
Mailing Address - Fax:620-417-7233
Practice Address - Street 1:407 N SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-3246
Practice Address - Country:US
Practice Address - Phone:620-417-7230
Practice Address - Fax:620-417-7233
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-17013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist