Provider Demographics
NPI:1649948183
Name:PHAN, ANDY KHOA (PHARMD)
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:KHOA
Last Name:PHAN
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 1:5016 W 5TH ST APT G
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92703-3190
Mailing Address - Country:US
Mailing Address - Phone:714-200-4516
Mailing Address - Fax:
Practice Address - Street 1:1026 S BROADWAY STE A
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-4779
Practice Address - Country:US
Practice Address - Phone:213-419-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84938183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist