Provider Demographics
NPI:1295087880
Name:PHAN, HUYEN L
Entity type:Individual
Prefix:
First Name:HUYEN
Middle Name:L
Last Name:PHAN
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 1:249 S 20TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-2714
Mailing Address - Country:US
Mailing Address - Phone:408-858-3551
Mailing Address - Fax:
Practice Address - Street 1:1400 FITZGERALD DR
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2250
Practice Address - Country:US
Practice Address - Phone:510-222-9281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68262183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist