Provider Demographics
NPI:1760886386
Name:PHAN, KATHY
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:PHAN
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 1:215 CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-2910
Mailing Address - Country:US
Mailing Address - Phone:530-665-4640
Mailing Address - Fax:
Practice Address - Street 1:215 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-2910
Practice Address - Country:US
Practice Address - Phone:530-665-4640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-10
Last Update Date:2017-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71729183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist