Provider Demographics
NPI:1992073860
Name:PHAN, TAMMY
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:PHAN
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 1:9371 IMPERIAL AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN
Mailing Address - State:CA
Mailing Address - Zip Code:92844-2314
Mailing Address - Country:US
Mailing Address - Phone:714-326-4865
Mailing Address - Fax:
Practice Address - Street 1:1826 W ORANGETHROPE AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833
Practice Address - Country:US
Practice Address - Phone:714-526-9257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54292183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist