Provider Demographics
NPI:1699312421
Name:PROUM, DANA
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:PROUM
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 1:1105 E KATELLA AVE UNIT 367
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-8706
Mailing Address - Country:US
Mailing Address - Phone:774-526-2663
Mailing Address - Fax:
Practice Address - Street 1:1105 E KATELLA AVE UNIT 367
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-8706
Practice Address - Country:US
Practice Address - Phone:774-526-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69827183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist