Provider Demographics
NPI:1336732163
Name:LE, PHONG TAN (RPH)
Entity Type:Individual
Prefix:
First Name:PHONG
Middle Name:TAN
Last Name:LE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4949 TIMBERCREEK WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95841-2260
Mailing Address - Country:US
Mailing Address - Phone:916-531-4967
Mailing Address - Fax:
Practice Address - Street 1:4949 TIMBERCREEK WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-2260
Practice Address - Country:US
Practice Address - Phone:916-531-4967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84016183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist