Provider Demographics
NPI:1417594508
Name:DIMANH, PHOUTTHAAPHAI BOBBY (PHARMD)
Entity Type:Individual
Prefix:
First Name:PHOUTTHAAPHAI
Middle Name:BOBBY
Last Name:DIMANH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 OAK PARK DR
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94131-1029
Mailing Address - Country:US
Mailing Address - Phone:214-878-3222
Mailing Address - Fax:
Practice Address - Street 1:590 OAK PARK DR
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94131-1029
Practice Address - Country:US
Practice Address - Phone:214-878-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-08
Last Update Date:2019-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH81231183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist