Provider Demographics
NPI:1760759757
Name:PHAM, JEANNIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6835 KATELLA AVE
Mailing Address - Street 2:T-0229
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-5107
Mailing Address - Country:US
Mailing Address - Phone:714-484-7557
Mailing Address - Fax:714-484-7557
Practice Address - Street 1:6835 KATELLA AVE
Practice Address - Street 2:T-0229
Practice Address - City:CYPRESS
Practice Address - State:CA
Practice Address - Zip Code:90630-5107
Practice Address - Country:US
Practice Address - Phone:714-484-7557
Practice Address - Fax:714-484-7557
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65551183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist