Provider Demographics
NPI:1386944379
Name:PHAN, MARIE MAR (PHARM D)
Entity type:Individual
Prefix:DR
First Name:MARIE
Middle Name:MAR
Last Name:PHAN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N LEMON AVE
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-2345
Mailing Address - Country:US
Mailing Address - Phone:909-595-7431
Mailing Address - Fax:909-595-7925
Practice Address - Street 1:350 N LEMON AVE
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-2345
Practice Address - Country:US
Practice Address - Phone:909-595-7431
Practice Address - Fax:909-595-7925
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47496183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist