Healthcare Provider Details

I. General information

NPI: 1609556786
Provider Name (Legal Business Name): KHOA DANG PHAM RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 SAN MATEO RD
HALF MOON BAY CA
94019-1706
US

IV. Provider business mailing address

3021 HUFF AVE APT 105
SAN JOSE CA
95128-3021
US

V. Phone/Fax

Practice location:
  • Phone: 650-726-2511
  • Fax:
Mailing address:
  • Phone: 408-833-0975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number87136
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: