Provider Demographics
NPI:1386746196
Name:PHOMMALAYHANE, BERLINDA
Entity type:Individual
Prefix:
First Name:BERLINDA
Middle Name:
Last Name:PHOMMALAYHANE
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 1:9057 ARROW RTE
Mailing Address - Street 2:SUITE 170
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4452
Mailing Address - Country:US
Mailing Address - Phone:909-466-6701
Mailing Address - Fax:909-476-7747
Practice Address - Street 1:9057 ARROW RTE
Practice Address - Street 2:SUITE 170
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4452
Practice Address - Country:US
Practice Address - Phone:909-466-6701
Practice Address - Fax:909-476-7747
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY47175183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1386746196Medicare NSC
CA5822470001Medicare PIN