MEDICARE: SANDRA KIM PHAN PHARM.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	61618	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	61618	OTHER	TX	PHARMACY

General Provider Information

NPI Number	:	1710506050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA KIM PHAN PHARM.D

Provider Business Mailing Address
First Line	:	31406 WESTON VILLAGE DR
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77386-2596
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7102 FM 1464 RD
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77407-6429
Country	:	US
Telephone Number	:	281-494-1984
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2020
Last Update Date	:	04/15/2020

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