Provider Demographics
NPI:1649676461
Name:PHAM, TRACY (PHARM D)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:PHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARM D
Mailing Address - Street 1:3030 HARBOR BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-2564
Mailing Address - Country:US
Mailing Address - Phone:714-979-6743
Mailing Address - Fax:
Practice Address - Street 1:3030 HARBOR BLVD STE A
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-2564
Practice Address - Country:US
Practice Address - Phone:714-979-6743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64235183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist