Provider Demographics
NPI:1710413810
Name:LE, VANANH PHAN
Entity Type:Individual
Prefix:
First Name:VANANH
Middle Name:PHAN
Last Name:LE
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 1:302 SOMERDALE RD
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-1846
Mailing Address - Country:US
Mailing Address - Phone:602-308-9536
Mailing Address - Fax:
Practice Address - Street 1:1210 ROUTE 130 N STE 1408
Practice Address - Street 2:
Practice Address - City:CINNAMINSON
Practice Address - State:NJ
Practice Address - Zip Code:08077-3046
Practice Address - Country:US
Practice Address - Phone:856-829-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03844000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist