Provider Demographics
NPI:1679105092
Name:PHAM, KIM NGAN T (PHARM D)
Entity Type:Individual
Prefix:
First Name:KIM NGAN
Middle Name:T
Last Name:PHAM
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 WELLNESS WAY # 110
Mailing Address - Street 2:
Mailing Address - City:VALLEY SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95252-9736
Mailing Address - Country:US
Mailing Address - Phone:209-772-9088
Mailing Address - Fax:
Practice Address - Street 1:51 WELLNESS WAY # 110
Practice Address - Street 2:
Practice Address - City:VALLEY SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95252-9736
Practice Address - Country:US
Practice Address - Phone:209-772-9088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist