Provider Demographics
NPI:1770028029
Name:PHAM, KATIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KATIE
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 1:13422 FALMOUTH PL
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-4711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13422 FALMOUTH PL
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-4711
Practice Address - Country:US
Practice Address - Phone:714-889-0988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75859183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist