Provider Demographics
NPI:1811369853
Name:TRAN, TOM
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:TRAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 S GREENWOOD AVE APT H
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-9407
Mailing Address - Country:US
Mailing Address - Phone:626-383-3536
Mailing Address - Fax:
Practice Address - Street 1:858 N SUNSET AVE
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-2548
Practice Address - Country:US
Practice Address - Phone:626-931-1410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56923183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist