Provider Demographics
NPI:1902227481
Name:PHAN, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
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 1:4809 CORNFLOWER STREET
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582
Mailing Address - Country:US
Mailing Address - Phone:214-907-1633
Mailing Address - Fax:
Practice Address - Street 1:15555 E. 14TH STREET #400
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578
Practice Address - Country:US
Practice Address - Phone:510-276-2699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-30
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66269183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist