Provider Demographics
NPI:1558761676
Name:PHAN, TRACY
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:
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 1:17835 GALE AVE
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91748-1526
Mailing Address - Country:US
Mailing Address - Phone:626-964-6267
Mailing Address - Fax:626-964-6901
Practice Address - Street 1:17835 GALE AVE
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91748-1526
Practice Address - Country:US
Practice Address - Phone:626-964-6267
Practice Address - Fax:626-964-6901
Is Sole Proprietor?:No
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA710794414183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist