Provider Demographics
NPI:1528432341
Name:PHAM, SIDNEY (RPH)
Entity type:Individual
Prefix:
First Name:SIDNEY
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 W TEFFT ST
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9187
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 W TEFFT ST
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-9187
Practice Address - Country:US
Practice Address - Phone:805-929-2740
Practice Address - Fax:805-929-3360
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71360183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist