Provider Demographics
NPI:1235503111
Name:PHAN, BRYAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
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 1:2982 WICKHAM CT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-8808
Mailing Address - Country:US
Mailing Address - Phone:443-616-6587
Mailing Address - Fax:
Practice Address - Street 1:2982 WICKHAM CT
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-8808
Practice Address - Country:US
Practice Address - Phone:443-616-6587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73877183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist