Provider Demographics
NPI:1295505097
Name:PHAM, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:PHAM
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 1:2040 FURLOW DR
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-1647
Mailing Address - Country:US
Mailing Address - Phone:951-442-2225
Mailing Address - Fax:
Practice Address - Street 1:7170 DAY CREEK BLVD
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-8821
Practice Address - Country:US
Practice Address - Phone:909-463-7846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89088183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist