Healthcare Provider Details

I. General information

NPI: 1598322125
Provider Name (Legal Business Name): VAN PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 07/25/2022
Certification Date: 07/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 BENTON ST
LOMA LINDA CA
92357-1000
US

IV. Provider business mailing address

7281 JUDSON AVE
WESTMINSTER CA
92683-6163
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone: 949-302-2460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number78949
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number78949
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: