Provider Demographics
NPI:1518634237
Name:PHAN, MONA TUONG-KHANH
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:TUONG-KHANH
Last Name:PHAN
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 1:4816 NW BETHANY BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-9254
Mailing Address - Country:US
Mailing Address - Phone:503-439-9014
Mailing Address - Fax:503-533-0579
Practice Address - Street 1:4816 NW BETHANY BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-9254
Practice Address - Country:US
Practice Address - Phone:503-439-9014
Practice Address - Fax:503-533-0579
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0018513183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist