Provider Demographics
NPI:1265832810
Name:PHAM, DAN
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6665 N FRESNO ST
Mailing Address - Street 2:APT 240
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-3728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7300 N FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2941
Practice Address - Country:US
Practice Address - Phone:559-448-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71330183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA71330OtherCALIFORNIA BOARD OF PHARMACY LICENSE NUMBER