Provider Demographics
NPI:1649744962
Name:LAI, PHUONG
Entity Type:Individual
Prefix:
First Name:PHUONG
Middle Name:
Last Name:LAI
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 1:956 WOODSIDE RD APT 20
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94061-3642
Mailing Address - Country:US
Mailing Address - Phone:916-504-0543
Mailing Address - Fax:
Practice Address - Street 1:909 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3505
Practice Address - Country:US
Practice Address - Phone:415-258-1649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79323183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist