Provider Demographics
NPI:1407163967
Name:MAILAN HERITAGE PHARMACY
Entity Type:Organization
Organization Name:MAILAN HERITAGE PHARMACY
Other - Org Name:MAILAN HERITAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC/CEO
Authorized Official - Prefix:
Authorized Official - First Name:PHUONG
Authorized Official - Middle Name:THI NGOC
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:714-899-4960
Mailing Address - Street 1:14441 BEACH BLVD
Mailing Address - Street 2:STE 108
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683
Mailing Address - Country:US
Mailing Address - Phone:714-899-4960
Mailing Address - Fax:714-876-6011
Practice Address - Street 1:14441 BEACH BLVD
Practice Address - Street 2:STE 108
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683
Practice Address - Country:US
Practice Address - Phone:714-899-4960
Practice Address - Fax:714-876-6011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-05
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY503163336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty