Provider Demographics
NPI:1275885410
Name:PHAN, SARAH T
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:T
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 1:80 RIO RANCHO RD
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-4771
Mailing Address - Country:US
Mailing Address - Phone:909-620-4077
Mailing Address - Fax:909-620-1918
Practice Address - Street 1:80 RIO RANCHO RD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-4771
Practice Address - Country:US
Practice Address - Phone:909-620-4077
Practice Address - Fax:909-620-1918
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51925183500000X
FLPS31800183500000X
NJ23501183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist