Provider Demographics
NPI:1104100304
Name:PHAM, KENNY HOA (PHARM D)
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:HOA
Last Name:PHAM
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:HOA
Other - Middle Name:XUAN
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARM D
Mailing Address - Street 1:16286 RAINIER ST.
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708
Mailing Address - Country:US
Mailing Address - Phone:714-548-7255
Mailing Address - Fax:
Practice Address - Street 1:292 LOS ALTOS PKWY
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89436
Practice Address - Country:US
Practice Address - Phone:775-354-0104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17592183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist