Provider Demographics
NPI:1073518627
Name:PHAN, DUNG NGOC (RPH)
Entity Type:Individual
Prefix:MISS
First Name:DUNG
Middle Name:NGOC
Last Name:PHAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4776 EL CAJON BLVD
Mailing Address - Street 2:STE 105
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-4521
Mailing Address - Country:US
Mailing Address - Phone:619-287-1206
Mailing Address - Fax:
Practice Address - Street 1:4776 EL CAJON BLVD
Practice Address - Street 2:STE 105
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-4521
Practice Address - Country:US
Practice Address - Phone:619-287-1206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 47041183500000X
CARPH470413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA435300Medicaid