Provider Demographics
NPI:1174148662
Name:PHAN, MINH DUC
Entity type:Individual
Prefix:
First Name:MINH
Middle Name:DUC
Last Name:PHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10135 TONY CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-4578
Mailing Address - Country:US
Mailing Address - Phone:209-406-9980
Mailing Address - Fax:
Practice Address - Street 1:975 S FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5118
Practice Address - Country:US
Practice Address - Phone:209-339-7595
Practice Address - Fax:209-369-7694
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60175183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist