Provider Demographics
NPI:1356939094
Name:PHAN, PHUC THANH (RPH)
Entity type:Individual
Prefix:DR
First Name:PHUC
Middle Name:THANH
Last Name:PHAN
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 1:323 N EUCLID ST SPC 119
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92703-3044
Mailing Address - Country:US
Mailing Address - Phone:714-510-6596
Mailing Address - Fax:
Practice Address - Street 1:15180 KENSINGTON PARK DR
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92782-1801
Practice Address - Country:US
Practice Address - Phone:714-259-7625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83629183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist