Provider Demographics
NPI:1417397498
Name:MOUA, PANG (RPH)
Entity Type:Individual
Prefix:
First Name:PANG
Middle Name:
Last Name:MOUA
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 1:3544 HIGGINS AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-2572
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1050 N WILSON WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-4218
Practice Address - Country:US
Practice Address - Phone:209-948-0950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA67844183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist