Provider Demographics
NPI:1427596378
Name:TRAN, DAT THI PHUONG
Entity Type:Individual
Prefix:
First Name:DAT
Middle Name:THI PHUONG
Last Name:TRAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17837 SANTA GERTRUDES CIR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-5022
Mailing Address - Country:US
Mailing Address - Phone:714-794-7352
Mailing Address - Fax:
Practice Address - Street 1:17837 SANTA GERTRUDES CIR
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-5022
Practice Address - Country:US
Practice Address - Phone:714-794-7352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH76152183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist