Healthcare Provider Details

I. General information

NPI: 1225636657
Provider Name (Legal Business Name): JADE NGOC LAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2020
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 SWEETWATER RD
SPRING VALLEY CA
91977-5627
US

IV. Provider business mailing address

543 SWEETWATER RD
SPRING VALLEY CA
91977-5627
US

V. Phone/Fax

Practice location:
  • Phone: 619-461-2100
  • Fax:
Mailing address:
  • Phone: 619-461-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number83428
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: