Provider Demographics
NPI:1073020657
Name:PHAN, PETER HOA (PHARMD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:HOA
Last Name:PHAN
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 1:275 W VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-8359
Mailing Address - Country:US
Mailing Address - Phone:805-233-3631
Mailing Address - Fax:805-233-3379
Practice Address - Street 1:275 W VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-8359
Practice Address - Country:US
Practice Address - Phone:805-233-3631
Practice Address - Fax:805-233-3379
Is Sole Proprietor?:No
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-12666183500000X
TX52877183500000X
CA71815183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist