Provider Demographics
NPI:1104462076
Name:PHAM, NAM H
Entity type:Individual
Prefix:
First Name:NAM
Middle Name:H
Last Name:PHAM
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 1:15041 SYRACUSE ST
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-6226
Mailing Address - Country:US
Mailing Address - Phone:714-716-9158
Mailing Address - Fax:
Practice Address - Street 1:15041 SYRACUSE ST
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-6226
Practice Address - Country:US
Practice Address - Phone:714-716-9158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79475183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist