Provider Demographics
NPI:1720694581
Name:PHAM, MARY (PHARMD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 N TUSTIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-6857
Mailing Address - Country:US
Mailing Address - Phone:714-760-4615
Mailing Address - Fax:714-475-1606
Practice Address - Street 1:1403 N TUSTIN AVE STE 150
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-6857
Practice Address - Country:US
Practice Address - Phone:714-760-4615
Practice Address - Fax:714-475-1606
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH51889183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist