Provider Demographics
NPI:1457048126
Name:PHAM, PHILLIP (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 W 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2236
Mailing Address - Country:US
Mailing Address - Phone:650-349-1373
Mailing Address - Fax:
Practice Address - Street 1:29 W 25TH AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2236
Practice Address - Country:US
Practice Address - Phone:650-349-1373
Practice Address - Fax:650-349-1745
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63752183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist