Provider Demographics
NPI:1659935146
Name:PHUNG, SON PHUOC (RPH)
Entity Type:Individual
Prefix:
First Name:SON
Middle Name:PHUOC
Last Name:PHUNG
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 1:20475 YORBA LINDA BLVD
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-3043
Mailing Address - Country:US
Mailing Address - Phone:714-630-6074
Mailing Address - Fax:714-693-3147
Practice Address - Street 1:20475 YORBA LINDA BLVD
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-3043
Practice Address - Country:US
Practice Address - Phone:714-630-6074
Practice Address - Fax:714-693-3147
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52449183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist