Provider Demographics
NPI:1770565079
Name:DO, SUSAN PHAN (PHARMACIST)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:PHAN
Last Name:DO
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7245 RESEDA BLVD
Mailing Address - Street 2:HADO PHARMACY
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-3046
Mailing Address - Country:US
Mailing Address - Phone:818-342-9333
Mailing Address - Fax:818-342-9320
Practice Address - Street 1:7245 RESEDA BLVD
Practice Address - Street 2:HADO PHARMACY
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-3046
Practice Address - Country:US
Practice Address - Phone:818-342-9333
Practice Address - Fax:818-342-9320
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH43236183500000X
CAPHY40601183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA406010Medicaid