Provider Demographics
NPI:1477215994
Name:PHAM, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PHAM
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 1:89 W MARCH LANE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-4418
Mailing Address - Country:US
Mailing Address - Phone:209-870-2760
Mailing Address - Fax:
Practice Address - Street 1:89 W MARCH LANE
Practice Address - Street 2:SUITE 2
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-4418
Practice Address - Country:US
Practice Address - Phone:209-870-2760
Practice Address - Fax:209-870-2769
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84756183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist