Provider Demographics
NPI:1386930592
Name:PHAM, KY JORDAN QUOC
Entity type:Individual
Prefix:
First Name:KY JORDAN
Middle Name:QUOC
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 1:16000 MONTEREY RD
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-5404
Mailing Address - Country:US
Mailing Address - Phone:408-778-5184
Mailing Address - Fax:
Practice Address - Street 1:16000 MONTEREY RD
Practice Address - Street 2:
Practice Address - City:MORGAN HILL
Practice Address - State:CA
Practice Address - Zip Code:95037-5404
Practice Address - Country:US
Practice Address - Phone:408-778-5184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50946183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist