Provider Demographics
NPI:1073980991
Name:PHAN, QUANG (PHARMD)
Entity Type:Individual
Prefix:
First Name:QUANG
Middle Name:
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 1:101 2ND AVE
Mailing Address - Street 2:APT 505
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-4782
Mailing Address - Country:US
Mailing Address - Phone:515-306-0808
Mailing Address - Fax:
Practice Address - Street 1:101 2ND AVE
Practice Address - Street 2:APT 505
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-4782
Practice Address - Country:US
Practice Address - Phone:515-306-0808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22574183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist