Provider Demographics
NPI:1740201714
Name:PHAN HEALTHCARE INC
Entity Type:Organization
Organization Name:PHAN HEALTHCARE INC
Other - Org Name:FOOTHILL RANCH MEDICAL PLAZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-586-6337
Mailing Address - Street 1:26750 TOWNE CENTRE DR
Mailing Address - Street 2:STE C
Mailing Address - City:FOOTHILL RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92610-2841
Mailing Address - Country:US
Mailing Address - Phone:949-586-6337
Mailing Address - Fax:949-586-0133
Practice Address - Street 1:26750 TOWNE CENTRE DR
Practice Address - Street 2:STE C
Practice Address - City:FOOTHILL RANCH
Practice Address - State:CA
Practice Address - Zip Code:92610-2841
Practice Address - Country:US
Practice Address - Phone:949-586-6337
Practice Address - Fax:949-586-0133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA472373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2113691OtherPK
CAPHA472370Medicaid