Provider Demographics
NPI:1225447121
Name:SAM, PHU CUONG QUANG (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:PHU CUONG
Middle Name:QUANG
Last Name:SAM
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18567 CALLENS CIR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6622
Mailing Address - Country:US
Mailing Address - Phone:714-489-3075
Mailing Address - Fax:
Practice Address - Street 1:760 WASHBURN AVE STE 1
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-3303
Practice Address - Country:US
Practice Address - Phone:951-371-2003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51470183500000X
NV14891183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist