Provider Demographics
NPI:1497588115
Name:PHAN, TRUC MONG
Entity type:Individual
Prefix:
First Name:TRUC
Middle Name:MONG
Last Name:PHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 CAPE KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95133-1512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 1ST ST
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-4976
Practice Address - Country:US
Practice Address - Phone:408-842-0373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89652183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist