Provider Demographics
NPI:1467434845
Name:LIEN THI KHONG
Entity Type:Organization
Organization Name:LIEN THI KHONG
Other - Org Name:MANNA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:SUSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-351-9776
Mailing Address - Street 1:10402 WESTMINSTER AVE
Mailing Address - Street 2:STE C
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-4861
Mailing Address - Country:US
Mailing Address - Phone:714-534-4133
Mailing Address - Fax:714-534-4052
Practice Address - Street 1:10402 WESTMINSTER AVE
Practice Address - Street 2:STE C
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-4861
Practice Address - Country:US
Practice Address - Phone:714-534-4133
Practice Address - Fax:714-534-4052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY500503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122922OtherPK
6477800001Medicare NSC
6477800001OtherMEDICARE NSC