Provider Demographics
NPI:1396376000
Name:PHAM, SON THIEN
Entity Type:Individual
Prefix:
First Name:SON
Middle Name:THIEN
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2575 E RILES CIR
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-5610
Mailing Address - Country:US
Mailing Address - Phone:714-548-8342
Mailing Address - Fax:
Practice Address - Street 1:2575 E RILES CIR
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-5610
Practice Address - Country:US
Practice Address - Phone:714-548-8342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82039183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist