Provider Demographics
NPI:1609556786
Name:PHAM, KHOA DANG (RPH)
Entity Type:Individual
Prefix:
First Name:KHOA
Middle Name:DANG
Last Name:PHAM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 HUFF AVE APT 105
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-3021
Mailing Address - Country:US
Mailing Address - Phone:408-833-0975
Mailing Address - Fax:
Practice Address - Street 1:170 SAN MATEO RD
Practice Address - Street 2:
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019-1706
Practice Address - Country:US
Practice Address - Phone:650-726-2511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87136183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist