Provider Demographics
NPI:1366799637
Name:PHAN, KHANH
Entity type:Individual
Prefix:
First Name:KHANH
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 1:15614 WHITTWOOD LN
Mailing Address - Street 2:T2019
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90603-2324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15614 WHITTWOOD LN
Practice Address - Street 2:T2019
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90603-2324
Practice Address - Country:US
Practice Address - Phone:562-371-9004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65399183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist