Healthcare Provider Details

I. General information

NPI: 1861065476
Provider Name (Legal Business Name): CHRISTINE LUU PHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2021
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 S 4TH AVE
POCATELLO ID
83201-6438
US

IV. Provider business mailing address

4170 HAWTHORNE RD APT A202
POCATELLO ID
83202-2710
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-3341
  • Fax:
Mailing address:
  • Phone: 949-683-8823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP9479
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: