Provider Demographics
NPI:1275081689
Name:PHAN, CECILIA
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:
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 1:3129 57TH AVENUE CIR E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-5327
Mailing Address - Country:US
Mailing Address - Phone:941-567-9438
Mailing Address - Fax:
Practice Address - Street 1:1490 US HIGHWAY 41 BYP S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-5544
Practice Address - Country:US
Practice Address - Phone:941-493-3925
Practice Address - Fax:941-493-9329
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist