Provider Demographics
NPI:1295055747
Name:PHAM, KEVIN (PHARMACIST)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 E GLADSTONE ST
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-4926
Mailing Address - Country:US
Mailing Address - Phone:626-334-3511
Mailing Address - Fax:626-812-7845
Practice Address - Street 1:153 E GLADSTONE ST
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-4926
Practice Address - Country:US
Practice Address - Phone:626-334-3511
Practice Address - Fax:626-812-7845
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist