Provider Demographics
NPI:1326644345
Name:PHAN, GIANG
Entity Type:Individual
Prefix:
First Name:GIANG
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 1:1925 VANCE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-2307
Mailing Address - Country:US
Mailing Address - Phone:281-919-7174
Mailing Address - Fax:
Practice Address - Street 1:286 W WALKER WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-1336
Practice Address - Country:US
Practice Address - Phone:260-244-3113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-06
Last Update Date:2020-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26028951A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist