Provider Demographics
NPI:1396021697
Name:PHAM, DERRICK THANH (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:THANH
Last Name:PHAM
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-4211
Mailing Address - Country:US
Mailing Address - Phone:626-857-0633
Mailing Address - Fax:
Practice Address - Street 1:550 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4211
Practice Address - Country:US
Practice Address - Phone:626-857-0633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66316183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist