Provider Demographics
NPI:1710518915
Name:PHAN, PHONG (PHARMD)
Entity Type:Individual
Prefix:
First Name:PHONG
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 S ARAPAHO DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-2407
Mailing Address - Country:US
Mailing Address - Phone:714-623-6607
Mailing Address - Fax:
Practice Address - Street 1:84 010 AVENUE 50
Practice Address - Street 2:
Practice Address - City:COACHELLA
Practice Address - State:CA
Practice Address - Zip Code:92236
Practice Address - Country:US
Practice Address - Phone:760-391-5656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80481183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist