Provider Demographics
NPI:1356625032
Name:PHAN, HENRY QUOC
Entity type:Individual
Prefix:MR
First Name:HENRY
Middle Name:QUOC
Last Name:PHAN
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 1:8835 CITRUS AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-5493
Mailing Address - Country:US
Mailing Address - Phone:714-638-8158
Mailing Address - Fax:
Practice Address - Street 1:8835 CITRUS AVE
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-5493
Practice Address - Country:US
Practice Address - Phone:714-638-8158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55460183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist