Healthcare Provider Details

I. General information

NPI: 1346786282
Provider Name (Legal Business Name): STEPHANIE PHAN PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 W 3RD AVE
ALBANY GA
31701-1943
US

IV. Provider business mailing address

1000 JEFFERSON ST
ALBANY GA
31701-2053
US

V. Phone/Fax

Practice location:
  • Phone: 229-312-2154
  • Fax: 229-312-2155
Mailing address:
  • Phone: 229-312-2154
  • Fax: 229-312-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License NumberRPH025626
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: