Provider Demographics
NPI:1396276705
Name:PHAN, YVONNE
Entity type:Individual
Prefix:
First Name:YVONNE
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:YVONNE YXUAN
Other - Middle Name:P
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8635 KINGSLYNN CT
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-3135
Mailing Address - Country:US
Mailing Address - Phone:916-531-5430
Mailing Address - Fax:
Practice Address - Street 1:2680 REYNOLDS RANCH PKWY
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-6848
Practice Address - Country:US
Practice Address - Phone:209-366-7301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45939183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist