Provider Demographics
NPI:1093074478
Name:PHAN, KATHY DONGTHI
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:DONGTHI
Last Name:PHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11111 MAC MURRAY ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-1016
Mailing Address - Country:US
Mailing Address - Phone:714-837-3802
Mailing Address - Fax:
Practice Address - Street 1:11111 MAC MURRAY ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-1016
Practice Address - Country:US
Practice Address - Phone:714-837-3802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56845183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist