Provider Demographics
NPI:1295010072
Name:PHAM, KELLY (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2529 CLIFFSIDE LN NW
Mailing Address - Street 2:APT # H204
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1686
Mailing Address - Country:US
Mailing Address - Phone:714-254-5208
Mailing Address - Fax:
Practice Address - Street 1:3099 BETHEL RD SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-2432
Practice Address - Country:US
Practice Address - Phone:360-876-3924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60233462183500000X
CO19262183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist