Provider Demographics
NPI:1336520097
Name:PHAN, VAN-QUYNH
Entity type:Individual
Prefix:
First Name:VAN-QUYNH
Middle Name:
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 1:45986 CAMINO RUBI
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-3389
Mailing Address - Country:US
Mailing Address - Phone:858-357-4776
Mailing Address - Fax:
Practice Address - Street 1:29676 RANCHO CALIFORNIA RD
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-5283
Practice Address - Country:US
Practice Address - Phone:951-693-2704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67882183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist