Provider Demographics
NPI:1427530880
Name:TRAN, PHUONG-DIEU LY
Entity type:Individual
Prefix:
First Name:PHUONG-DIEU
Middle Name:LY
Last Name:TRAN
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 1:160 DIAMOND DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 DIAMOND DRIVE
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530
Practice Address - Country:US
Practice Address - Phone:951-674-3562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-02
Last Update Date:2018-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78378183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist