Provider Demographics
NPI:1982104337
Name:PHAM, DUYEN
Entity Type:Individual
Prefix:
First Name:DUYEN
Middle Name:
Last Name:PHAM
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 1:281 FONZIE AVE
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-8860
Mailing Address - Country:US
Mailing Address - Phone:949-378-9375
Mailing Address - Fax:
Practice Address - Street 1:2150 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-1605
Practice Address - Country:US
Practice Address - Phone:760-337-1608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48364183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist