Provider Demographics
NPI:1710506050
Name:PHAN, SANDRA KIM (PHARMD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:KIM
Last Name:PHAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:KIM
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:31406 WESTON VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-2596
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7102 FM 1464 RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-6429
Practice Address - Country:US
Practice Address - Phone:281-494-1984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61618183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX61618OtherPHARMACY