Provider Demographics
NPI:1174095194
Name:PHAN, THI HAI DUONG
Entity type:Individual
Prefix:
First Name:THI HAI DUONG
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HAI DUONG
Other - Middle Name:
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:308 TONOPAH AVE
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-3532
Mailing Address - Country:US
Mailing Address - Phone:626-757-3481
Mailing Address - Fax:
Practice Address - Street 1:4200 TRABUCO RD
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620-3600
Practice Address - Country:US
Practice Address - Phone:949-861-3170
Practice Address - Fax:949-861-3179
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA778083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy