Provider Demographics
NPI:1306446935
Name:TRAN, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:TRAN
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 1:81875 AVENUE 48 APT 171
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-6720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:49980 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-9720
Practice Address - Country:US
Practice Address - Phone:760-771-8848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-01
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83026183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist