Provider Demographics
NPI:1336122423
Name:PHO, LETU (RPH)
Entity Type:Individual
Prefix:MS
First Name:LETU
Middle Name:
Last Name:PHO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-3614
Mailing Address - Country:US
Mailing Address - Phone:714-542-8865
Mailing Address - Fax:714-542-9136
Practice Address - Street 1:520 W 17TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-3614
Practice Address - Country:US
Practice Address - Phone:714-542-8865
Practice Address - Fax:714-542-9136
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY43967183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA439670Medicaid
CAPHA439670Medicaid