Provider Demographics
NPI:1437769569
Name:PHAN, PETER PHU
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:PHU
Last Name:PHAN
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 1:3106 SOLOMONS ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3106 SOLOMONS ISLAND RD
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037-1701
Practice Address - Country:US
Practice Address - Phone:410-956-8319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27424183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist